Specialised infant formulae subsidised on the pharmaceutical schedule, i.e. extensively hydrolysed formula (eHF) or
amino acid formula (AAF), are only appropriate for infants with cows’ milk protein allergy (CMPA) who are unable to be
CMPA is an immunologically mediated adverse reaction to cows’ milk protein, with a prevalence of approximately 2–3%
in children before the age of three years. Allergic reaction to cows’ milk protein can be IgE or non-IgE mediated, and
there is a wide spectrum of possible reactions, ranging from mild gastrointestinal manifestations through to anaphylaxis.
Diagnosis can be challenging, and it is generally recommended that children with suspected CMPA are referred to a paediatrician
For further information on diagnosing CMPA, see: “Managing cows’ milk protein
allergy in infants”
Despite being highly tolerable, AAF is approximately three times more expensive to produce than eHF, and eHF will be
sufficiently hypoallergenic in the majority of infants with CMPA.1, 2 In New Zealand, this more expensive and “last-line”
AAF is currently being overprescribed. The expected prescribing ratio for eHF to AAF should be approximately 3:1, pharmaceutical
dispensing data from 2019 indicates that under the current subsidy criteria it is an almost 1:1 ratio.
Choosing the right formula
The age of the infant and the clinical characteristics of the CMPA should determine the type of formula most appropriate
as an initial option. However, in the majority of cases, eHF is recommended as the first-line choice of infant formula
for CMPA (Table 1).4, 5 CMPA symptoms resolve in approximately 90% of infants that transition to eHF.6 Soy-based formula
is not funded in New Zealand but is comparable in price to standard cows’ milk formula.
Other formulas such as goats’-milk based, lactose-free and partially hydrolysed formula are not suitable for infants
with CMPA, and “milk beverages”, such as rice or almond milk, are nutritionally inadequate and therefore not recommended
as a substitute for breast or cows’ milk.6
When to choose amino acid formula (AAF)
For the majority of infants with CMPA, eHF (or soy if the infant is aged more than six months) should be considered
first. Amino acid formula should only be considered as a first line-option in infants with CMPA and:8
- Eosinophilic esophagitis
- Severe intolerance, allergy or malabsorption on eHF
- Growth faltering, particularly with multisystem involvement and multiple food exclusions
It is estimated that only 10% of infants with CMPA will require AAF.5
Encouraging re-challenge of other options
In most cases, CMPA is a self-limiting condition; resolving between the ages of one to three years in many children.3
In addition, most children have a reduced requirement for milk once they are aged over 12 months and should be able to
progress to solids as their primary source of nutrition, meaning that dependence on AAF can be avoided or reduced. Therefore,
in the long-term it is important to regularly review and consider a cows’ milk challenge to avoid unnecessary dietary
restriction.4, 5 This is required for AAF Special Authority subsidy renewals (which are valid for six months), in addition
to trialling other non-AAF formula options, i.e. eHF and soy. The optimal interval for re-challenge is dependent on several
factors including age, severity of symptoms and evidence of an immunological reaction to CMPA.
From 1 July, 2020, the existing Special Authority approval for AAF will be replaced, and applications for children 12
months of age and older will need to be made by a paediatrician, paediatric gastroenterologist or paediatric immunologist,
or by a dietician on the recommendation of one of these specialists. Primary care will now need to ensure children likely
to still be using AAF and who will be aged 12 months at their next renewal are referred to a dietician, paediatrician,
paediatric gastroenterologist or paediatric immunologist before this time.
Table 1: Appropriate choice of formula feed in infants with CMPA syndromes in primary care.4 ,7
(if first not tolerated)
|Acute allergic reaction
|eHF or soy* (if aged >6 months)
||eHF (if soy was trialled first) or AAF†
||AAF (with urgent referral)
|Mixed immune response (IgE- and non-IgE)
|Atopic dermatitis (eczema)
||eHF or soy* (if aged >6 months)
||eHF (if soy was trialled first) or AAF†
|Food protein-induced enterocolitis syndrome
|Food protein-induced proctocolitis
|Gastrointestinal syndromes, GORD, allergic eosinophilic gastroenteritis, food protein-induced enteropathy, constipation, severe irritability (colic)
||eHF or soy* (if aged >6 months)
||eHF (if soy was trialled first) or AAF†
* Soy formula is not funded but may be used as an alternative to eHF for some infants with mild CMPA symptoms.
† eHF must first be trialled first for 2–4 weeks and found to be inappropriate due to severe intolerance, allergy or malabsorption.
AAF, amino acid formula; eHF, extensively hydrolysed formula; GORD, gastro-oesophageal reflux disease
Identify infants in the practice who have been prescribed AAF in the previous twelve months. Assess whether they have
documented evidence of an indication for AAF, whether they have previously trialled another formula, and whether they
have attempted re-challenge or an appointment has been scheduled with a specialist if they will be aged over 12 months
at their next Special Authority renewal.
Criteria for a positive outcome
A patient is considered a “positive outcome” for the purposes of the audit if they have been prescribed AAF, and have:
- A documented diagnosis of CMPA
- Evidence in their notes that they have an indication for AAF: anaphylaxis, eosinophilic oesophagitis, or eHF is
inappropriate due to severe intolerance, allergy or malabsorption
- Evidence in their notes that they have been re-challenged on cows’ milk, a re-challenge is planned, or an appointment
has been scheduled with a specialist if they will be aged over 12 months at their next renewal
A recommended standard would be for 90% of infants prescribed AAF to have a valid indication for receiving this formula,
if appropriate have previously tried eHF and re-challenge attempted or planned. There should ideally be an improvement
in the achieved percentage between the first and second audit cycles.
Any infant that has been prescribed AAF.
You will need to have a system in place that allows you to identify eligible patients. Many practices will be able to
identify patients by running a “query” through their PMS system. We suggest you identify all infants who have had a prescription
for amino acid formula in the previous 12 months.
The number of eligible patients will vary according to your practice demographic. It is unlikely that a large number
of results will be returned, but if so, take a random sample of 20–30 patients whose notes you will audit.
Use the data sheets provided to record your first and second cycles. In each data set, calculate the number of “positives”
by dividing the total number of infants prescribed AAF by the number of “Yes” results in the final column.
The recording of the indication should be used to help evaluate future practice and identify any areas of infant formula
prescription or re-challenging that could be improved within the practice.
The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.
Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.
It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).
Problem solving process
- What is the problem or underlying problem(s)?
- Change it to an aim
- What are the solutions or options?
- What are the barriers?
- How can you overcome them?
Overcoming barriers to promote change
- Identifying barriers can provide a basis for change
- What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them
in the practice setting
- Identify the barriers
- Develop a priority list
- Choose one or two achievable goals
- No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed
to bring about lasting change
- Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance
Monitoring change and progress
It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:
- Is the process working?
- Are the goals for improvement being achieved?
- Are the goals still appropriate?
- Do you need to develop new tools to achieve the goals you have set?
Following the completion of the first cycle, it is recommended that the doctor completes the first part of the
of Medical Practice summary sheet (Appendix 1).
Undertaking a second cycle
In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order
to quantify progress on closing the gaps in performance.
It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle
should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices
complete the remainder of the Audit of Medical
Practice summary sheet.
Claiming credits for Continuing Professional Development (CPD)
This audit has been endorsed by The Royal New Zealand College of General Practitioners (RNZCGP) and has been approved for 10 CME credits for a first cycle and 10 CME credits for a second cycle for the General Practice Educational Programme (GPEP) and Continuing Professional Development (CPD) purposes. The second cycle is optional and only two cycles are permissible.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
Record your completion of the audit on the CPD Online Dashboard, under the Audit of Medical Practice section.
From the drop down menu select “Approved practice/PHO audit” and record the audit name.
General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.
As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).
- PHARMAC. Proposal to change access to amino acid infant formula. Available from:
https://www.pharmac.govt.nz/news/consultation-2019-07-16-infant-formula/ (Accessed Nov, 2019).
- Special Foods Sub committee of the Pharmacology and Therapeutics Advisory Committee (PTAC). Minutes of the meeting
held 22 July 2015. Available from:
https://www.pharmac.govt.nz/assets/ptac-special-foods-subcommittee-minutes-2015-07.pdf (Accessed Nov, 2019).
- Flom JD, Sicherer SH. Epidemiology of cow’s milk allergy. Nutrients 2019;11:1051.
- Venter C, Brown T, Meyer R, et al. Better recognition, diagnosis and management of non-IgE-mediated cow’s milk allergy
in infancy: iMAP—an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy
- Fox A, Brown T, Walsh J, et al. An update to the Milk Allergy in Primary Care guideline. Clin Transl Allergy 2019;9:40.
- Lifschitz C, Szajewska H. Cow’s milk allergy: evidence-based diagnosis and management for the practitioner. Eur J
Pediatr 2015;174:141–50. http://dx.doi.org/10.1007/s00431-014-2422-3
- Vandenplas Y. Prevention and management of cow’s milk allergy in non-exclusively breastfed infants. Nutrients 2017;9:731.
- Meyer R, Groetch M, Venter C. When should infants with cow’s milk protein allergy use an amino acid formula? A practical
guide. The Journal of Allergy and Clinical Immunology: In Practice 2018;6:383–99.