For healthcare professionals only.

This formulary decision guide was developed from content provided by Mead Johnson Nutrition in a format developed by Guidelines in Practice.

Key points

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Combined logos

  • CMA is the most common childhood food allergy affecting 2–7.5% of infants1
  • Key clinical guidelines recommend extensively hydrolysed formula (eHF) as first-line management for formula-fed infants with mild-to-moderate CMA2–4
  • Nutramigen* LGG® has demonstrated short-term (symptom relief),5-7 medium-term (accelerated return to milk[A]),8,9 and long‑term (reduced future allergic manifestations10[B] and functional gastrointestinal disorders11[C]) benefits.

Download a PDF of this formulary decision guide here

Product name

Nutramigen* 1, 2 & 3 LGG®

Indication

  • Nutramigen* LGG® is an eHF with LGG (probiotic) for dietary management of infants with CMA, providing age-adapted nutrition to support normal growth,12 symptom relief,5-7 and an accelerated return to milk vs other formula.9[A]

Feeding guide

Age

Nutramigen* LGG®

Tins per month

0–6 months

1

9–10

6–12 months

2

5–6

≥1 year

3

5

See tin label for detailed feeding guidance; HCP to determine the formula intake based on the individual situation

Preparation and storage

  • Wash hands; clean feeding utensils in water (≥10 minutes rolling boil)
  • Boil fresh water; as soon as possible cool to room temperature; do not use softened water
  • Add powder and shake for at least a minute until completely dissolved
  • Feed immediately or cover and store in a refrigerator at 2–4°C for ≤24 hours
  • Store tin in a cool, dry place; after opening, keep tightly covered and use within 1 month.

Precautions

  • Do not freeze prepared formula and do not use if unrefrigerated for >2 hours
  • Use formula that has been in contact with baby’s mouth within 1 hour and do not refrigerate
  • Do not heat prepared formula in a microwave.

Monitoring

  • Trial formula for up to 4 weeks to allow symptom recovery and formula acceptance2
  • To confirm diagnosis of non IgE mediated allergy, reintroduce milk and monitor whether symptoms return2[D]
  • Guidelines recommend eHF for formula-fed infants for up to 2 years or until allergy is outgrown13
  • ~50% of CMA infants remain allergic at 1 year of age with most reaching oral tolerance by the age of 3 years14
  • A ‘planned reintroduction’ by an HCP will determine whether tolerance to milk protein has been acquired.2[D]

About CMA

  • CMA is an adverse immune reaction to cow’s milk protein, presenting with immediate (IgE mediated) and/or delayed (non IgE mediated) symptoms4
  • Prevalence in infants is 2–7.5%1
  • Children with CMA have an increased risk of other allergic manifestations.10

Guideline recommendations

  • For formula-fed infants, expert guidelines recommend eHF for first-line management of mild-to-moderate CMA2,4
  • Hypoallergenic formulas (eHF and AAF) should be tolerated by 90% of children with CMA (with a 95% confidence interval). On average 10% of children with IgE-mediated CMA continue to react to an eHF. For those infants an AAF may be indicated.15

Evidence of use

  • Short-term: effective symptom relief:5-7
    • average clinical efficacy[E] of 99%3
  • Medium-term: faster oral tolerance acquisition:[A]
    • Approx 80% of infants return to milk after 12 months of use9
  • Long-term: reduction in future allergic manifestations:[B]
    • incidence of ≥1 other allergic manifestation (asthma, eczema, urticaria, rhinoconjunctivitis) reduced by ~50% as shown in Figure 1.10

Figure 1

Budgetary implications

  • Nutramigen* LGG® has been shown to be a cost-effective dietetic strategy, saving the NHS £497 over 3 years and £907 over 5 years per infant compared with an eHF alone.16[F]

Cautions

  • Not recommended for premature and immunocompromised infants unless directed and supervised by an HCP
  • Babies fed eHF may produce frequent loose stools of a greenish colour (not unusual)
  • eHF tastes different to routine formulas but is well accepted by young infants.

Order and contact information

UK pharmacy PIP order code

Nutramigen* LGG®
(400 g)

Age  

NHS price

019-8861

1

0-6 months

£11.21

298-7766

2

6‑12 months

£11.21

406-4325

3

≥1 year

£11.21

For queries or milk-free recipes, please call the Mead Johnson Careline 01895 230575 or visit www.nutramigen.co.uk

AAF=amino acid-based formula; CMA=cow’s milk allergy; eHF=extensively hydrolysed formula; HCP=healthcare professional; LGG=Lactobacillus rhamnosus GG. 

[A] vs an eHF without LGG® or formulas based on rice hydrolysate, soya, or amino acids after 12 months of dietary management; 

[B] at least one of the following allergic episodes: rhino conjunctivitis, urticaria, eczema, and asthma during a period of 36 months compared to an eHF alone;

[C] vs eHF alone in children from 4-6 years of age;

[D] for useful information see: https://gpifn.org.uk/imap/;

[E] efficacy data calculated using data on allergic reactions after oral food challenge with an eHF, from Table 3 of Dupont et al. 2012. As judged by the Committee on Nutrition of the French Society of Paediatrics. Efficacy data was calculated based on studies with Nutramigen before the addition of LGG;

[F] for IgE mediated CMA.

References

  1. Vandenplas Y, Brueton M, Dupont C et al. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants Arch Dis Child 2007; 92 (10): 902–908.
  2. Fox A, Brown T, Walsh, J et al. An update to the milk allergy in primary care guideline. Clinical and translational allergy 2019; 9 (1): 1–7.
  3. Dupont C, Chouraqui J, de Boissieu D et al. Dietary treatment of cows’ milk protein allergy in childhood: a commentary by the Committee on Nutrition of the French Society of Paediatrics Br J Nutr 2012; 107 (3): 325–338.
  4. Luyt D, Ball H, Makwana M et al. BSACI guideline for the diagnosis and management of cow’s milk allergy. Clin Exp Allergy 2014; 44 (5): 642–672.
  5. Baldassarre M, LaForgia N, Fanelli M et al. Lactobacillus GG improves recovery in infants with blood in the stools and presumptive allergic colitis compared with extensively hydrolyzed formula alone. J Pediatr 2010; 156 (3): 397–401.
  6. Lothe L, Lindberg T. Cow’s milk whey protein elicits symptoms of infantile colic in colicky formula-fed infants: a double blind crossover study. Pediatrics 1989; 83: 262-266. 
  7. Nermes M, Kantele JM, Atosuo, TJ et al. Interaction of orally administered Lactobacillus rhamnosus GG with skin and gut microbiota and humoral immunity in infants with atopic dermatitis. Clinical & Experimental Allergy 2011;41: 370–377.
  8. Berni Canani R, Nocerino R, Terrin G et al. Effect of Lactobacillus GG on tolerance acquisition in infants with cow’s milk allergy: a randomized trial. J Allergy Clin Immunol 2012; 129 (2): 580–582.
  9. Berni Canani R, Nocerino R, Terrin G et al. Formula selection for management of children with cow’s milk allergy influences the rate of acquisition of tolerance: A Prospective Multicenter Study. J Pediatr 2013;163 : 771-777.
  10. Berni Canani R, Di Costanzo R, Bedogni G et al. Extensively hydrolyzed casein formula containing Lactobacillus rhamnosus GG reduces the occurrence of other allergic manifestations in children with cow’s milk allergy: 3-year randomized controlled trial J Allergy Clin Immunol 2017; 139 (6): 1906–1913.
  11. Nocerino R, Di Costanzo R, Bedogni G et al. Dietary treatment with extensively hydrolyzed casein formula containing the probiotic Lactobacillus rhamnosus GG prevents the occurrence of functional gastrointestinal disorders in children with cow’s milk allergy. J Pediatr 2019; 1-6.
  12. Scalabrin D, Johnston W, Hoffman D et al. Growth and tolerance of healthy term infants receiving hydrolyzed infant formulas supplemented with Lactobacillus rhamnosus GG: randomized, double-blind, controlled trial. Clin Pediatr (Phila) 2009; 48 (7): 734–744.
  13. Fiocchi A, Brozek J, Schunemann H et al. World Allergy Organization (WAO) diagnosis and rationale for action against cow’s milk allergy (DRACMA) guidelines. World Allergy Organ J 2010; 3 (4): 57–161.
  14. GIKids. Cow’s milk protein intolerance. 2019. Available at: https://gikids.org/digestive-topics/cows-milk-protein-allergy/ (accessed September 2020)
  15. Meyer R, Groetch M, Venter C. When should infants with cow’s milk protein allergy use an amino acid formula? A practical guide. J Allergy Clin Immunol Pract 2018; 6 (2): 383–399.
  16. Guest F, Singh H. Cost-effectiveness of using an extensively hydrolyzed casein formula supplemented with Lactobacillus rhamnosus GG in managing IgE mediated cow’s milk protein allergy in the UK. Current Medical Research and Opinion 2019; 35 (10); 1677-1685.

*Trademark of Mead Johnson & Company, LLC. © 2020 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Chr. Hansen A/S, Finland. Nutramigen with LGG® is a food for special medical purposes and must be used under medical supervision. Mead Johnson Nutrition is a company of Reckitt Benckiser.

Important notice: Breastfeeding provides the best nutrition for babies. 

Nutramigen LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional.

RB-M-18259

Date of preparation: October 2020