Hypoallergenic formula prescribing practices in Australia

Trends in use of specialised formula for managing cow's milk allergy in young children

BACKGROUND

Excessive use of specialised formula for cow's milk allergy was reported in England, but complete analysis has not been undertaken and trends in other countries are unknown. Some specialised formula products, especially amino-acid formula, have high free sugars content. We evaluated specialised formula trends in countries with public databases documenting national prescription rates.

METHODS

Cross-sectional analysis of national prescription databases in United Kingdom, Norway and Australia. Outcomes were volume and cost of specialised formula, and proportion of infants prescribed specialised formula. Expected volumes assumed 1% cow's milk allergy incidence and similar formula feeding rates between infants with and without milk allergy.

RESULTS

Prescribed volumes of specialised formula for infants rose 2.8-fold in England from 2007-2018, with similar trends in other regions of the United Kingdom. Volumes rose 2.2-fold in Norway from 2009-2020 and 3.2-fold in Australia from 2001-2012. In 2020, total volumes were 9.7 to 12.6-fold greater than expected in England, 8.3 to 15.6-fold greater than expected in Norway and 3.3 to 4.5-fold greater than expected in Australia, where prescribing restrictions were introduced in 2012. In Norway the proportion of infants prescribed specialised formula increased from 2.2% in 2009 to 6.9% in 2020, or 11.2 to 13.3-fold greater than expected. In 2020, specialised formula for infants cost US$117 (103 euro) per birth in England, US$93 (82 euro) in Norway and US$27 (23 euro) in Australia. Soya formula prescriptions exceeded expected volumes 5.5 to 6.4-fold in England in 1994 and subsequently declined, co-incident with public health concerns regarding soya formula safety. In 2020, 30-50% of prescribed specialised formula across the three countries was amino-acid formula.

CONCLUSIONS

In England, Norway and Australia, specialised formula prescriptions increased in the early 21^st century and exceeded expected levels. Unnecessary specialised formula use may make a significant contribution to free sugars consumption in young children.

Impact of soy consumption on human health: integrative review

Abstract Soy consumption is a millenary habit of populations of the eastern world and has recently increased in the western world. The risks and benefits of this practice have been extensively studied, with a current fundamental need of integration of available information. The aim of this study was to carry out an integrative review on this topic, in order to consolidate the available information. Based on the main question: “What is the impact of soy consumption on human health?”, were reviewed publications classified as original articles and reviews published from 1998 to 2020 in the databases Scopus, PubMed, SciELO, Web of Science, and Cochrane Library. A total of 97 studies were selected. In the present review were described the general impact of soy on human health and its protein quality, the effects of early exposure using soy formulas, and the effects of soy consumption on breast cancer, endometrial and ovarian cancer, prostate cancer, gastrointestinal cancer, cardiovascular disease, glucose metabolism and type 2 diabetes, obesity, reproductive health, menopause, female and male osteoporosis, microbiota, immunity and immunomodulation, thyroid function, attention-deficit hyperactivity disorder, and renal function.

A Critical Review of the Marketing Claims of Infant Formula Products in the United States

A highly competitive infant formula market has resulted in direct-to-consumer marketing intended to promote the sale of modified formulas that claim to ameliorate common infant feeding problems. The claims associated with these marketing campaigns are not evaluated with reference to clinical evidence by the Food and Drug Administration. We aimed to describe the language of claims made on formula labels and compare it with the evidence in systematic reviews. Of the 22 product labels we identified, 13 product labels included claims about colic and gastrointestinal symptoms. There is insufficient evidence to support the claims that removing or reducing lactose, using hydrolyzed or soy protein or adding pre-/probiotics to formula benefits infants with fussiness, gas, or colic yet claims like "soy for fussiness and gas" encourage parents who perceive their infants to be fussy to purchase modified formula. Increased regulation of infant formula claims is warranted.

Studies using Australia's Pharmaceutical Benefits Scheme data for pharmacoepidemiological research: a systematic review of the published literature (1987-2013)

PURPOSE

Research using dispensing claims is used increasingly to study post-market medicines use and outcomes. The purpose of this review is to catalogue more than 25 years of published literature using Australia's Pharmaceutical Benefits Scheme (PBS) dispensing records.

METHODS

We searched MEDLINE, PreMEDLINE and Embase and conducted author searches for studies published from 1987 to 2013. Independent reviewers screened abstracts of 3209 articles and reviewed 264 full-text manuscripts. Included studies used PBS dispensing data to measure patterns and/or outcomes of prescribed medicines use or dispensing claims to derive a proxy for a specific disease cohort or health outcome.

RESULTS

Of the 228 studies identified, 106 used PBS claims only (56 using claims-level data and 50 using individual-level data) and 63 studies linked individual-level PBS claims to other health data. Most commonly, studies examined trends in drug utilisation (33%), clinician and patient practices (26%), drug use and outcomes (18%) and evaluations of intervention impacts (17%). Sixty-two percent of studies using individual-level data were based on a subset of elderly Australians. Most studies focused on drug classes acting on the nervous system (36%), cardiovascular system (15%) and alimentary tract (11%). Few studies examined prescribed medicines use in children and pregnant women.

CONCLUSIONS

Pharmaceutical Benefits Scheme claims represent a significant resource to examine Australia's billion-dollar annual investment in prescribed medicines. The body of research is growing and has increased in complexity over time. Australia has great potential to undertake world-class, whole-of-population pharmacoepidemiological studies. Recent investment in data linkage infrastructure will significantly enhance these opportunities.

Clinical aspects of pediatric food allergy and failed oral immune tolerance

Food allergy seems to represent a new spectrum of disease that has elicited significant community concern and extended waiting lists for allergists and gastroenterologists alike. The apparent rise in prevalence of IgE-mediated food allergy (and associated risk of anaphylaxis) has been postulated to result from effects of a "modern lifestyle" but as yet clear environmental risk factors have not yet emerged. Family history seems to contribute to risk suggesting that gene-environment interactions will be important for identifying a subpopulation with increased susceptibility to any identified lifestyle effects. Non-IgE-mediated food allergy (including food-induced enteropathies and colitides, eosinophilic esophagitis, and Crohn's disease) with potentially similar environmental triggers resulting in diverse immune dysregulatory mechanisms. The evidence underpinning the putative rise in food allergy is discussed and potential mechanisms of disease explored. Clinical aspects of various food allergic conditions including non-IgE-mediated food allergy are outlined.

Modelling the resource implications and budget impact of managing cow milk allergy in Australia

OBJECTIVE

To estimate the resource implications and budget impact of current clinical practice for managing cow milk allergy (CMA) in Australia, from the perspective of the publicly funded healthcare system.

METHODS

A decision model was constructed using published clinical outcomes and clinician-derived resource utilisation estimates. The model was used to estimate the expected 6-monthly levels of healthcare resource use and corresponding costs attributable to managing 6150 new CMA sufferers following referral to a specialist.

RESULTS

The expected 6-monthly costs of managing 6150 newly-diagnosed infants with CMA following referral to a specialist was an estimated (Australian dollars, AU$) AU$6.5 million at 2006/07 prices. Clinical nutrition preparations were found to be the primary cost driver accounting for 62% of the total 6-monthly cost and clinician visits were the secondary cost driver accounting for up to a further 28% of the total 6-monthly cost. Sensitivity analysis showed there would be fewer visits to hospital-based paediatric gastroenterologists and paediatric immunologists/allergists if all newly-diagnosed patients were prescribed an amino acid formula (AAF) following referral to a specialist, instead of being managed according to current practice.

CONCLUSION

CMA imposes a substantial burden on the publicly funded healthcare system in Australia. However, using an AAF as the initial treatment for CMA can potentially release limited hospital resources for alternative use within the paediatric healthcare system.

Hypoallergenic formulas: optimal choices for treatment versus prevention

OBJECTIVES

To provide information on certain formulas that are relevant to allergy practice, focusing on their protein source and allergenicity, and to provide recommendations for selecting an optimal formula, taking into consideration efficacy, safety, palatability, and cost.

DATA SOURCES

A literature search using the PubMed database for the following keywords: hypoallergenic formulas, infant formulas, hydrolysate formulas, elemental formulas, and amino acids formulas.

STUDY SELECTION

Information was derived from pertinent original studies and selected reviews, including recent Cochrane Database Systematic Reviews, published in the English-language literature.

RESULTS

For a formula to be considered hypoallergenic, it should be well tolerated by at least 90% of individuals who are allergic to the parent protein from which that formula has been derived. Extensively hydrolyzed formulas (EHFs), derived from bovine casein or whey, are tolerated by approximately 95% of cow's milk allergic individuals. Elemental formulas are prepared from synthesized free amino acids and are well tolerated practically by all individuals, including those who are allergic to EHFs. Partially hydrolyzed whey formula (PHWFs) cause allergy in one-third to half of milk allergic individuals and are not considered hypoallergenic. Both EHFs and PHWFs seem to be equally effective in reducing the risk of development of allergy in infants of atopic families.

CONCLUSION

The EHFs and amino acids formulas, but not the partially hydrolyzed formulas, are optimal for milk allergic individuals. All 3 types of formulas are useful for prevention. The cost and palatability should be considered in deciding which formula to use.

Guidelines for the use of infant formulas to treat cows milk protein allergy: an Australian consensus panel opinion

Three types of infant formula (soy, extensively hydrolysed and amino acid) may be appropriate for treating cows milk protein allergy. Selection of a formula depends on the allergy syndrome to be treated. Extensively hydrolysed formula is recommended as first choice for infants under 6 months of age for treating immediate cows milk allergy (non-anaphylactic), food protein-induced enterocolitis syndrome, atopic eczema, gastrointestinal symptoms and food protein-induced proctocolitis. Soy formula is recommended as first choice for infants over 6 months of age with immediate food reactions, and for those with gastrointestinal symptoms or atopic dermatitis in the absence of failure to thrive. Amino acid formula is recommended as first choice in anaphylaxis and eosinophilic oesophagitis. If treatment with the initial formula is not successful, use of an alternative formula is recommended.

Paediatric food allergy trends in a community-based specialist allergy practice, 1995-2006

OBJECTIVE

To examine changing demand for specialist food allergy services for children aged 0-5 years over the 12 years from 1995 to 2006 as an index of changing prevalence.

DESIGN, SETTING AND PARTICIPANTS

Retrospective analysis of the records of 1489 children aged 0-5 years referred to a community-based specialist allergy practice in the Australian Capital Territory (population, about 0.33 million).

MAIN OUTCOME MEASURES

Trends in demand for assessment for food allergy, dietary triggers and severity over 12 years, compared with Australian hospital morbidity data.

RESULTS

47% (697/1489) of 0-5 year-old children seen in private practice had food allergy (175 with food-associated anaphylaxis), most commonly to peanut, egg, cows milk and cashew. Over 12 years, the number of children in this age group evaluated each year increased more than fourfold, from 55 cases in 1995 to 240 in 2006. There was no change in the proportion diagnosed with allergic rhinitis in 1995 and 2006 (14.5% and 13.3%, respectively), urticaria (14.5% and 12.9%) or atopic eczema (54.5% and 57.0%). By contrast, the proportion with asthma dropped from 33.7% in 1995 to 12.5% in 2006 and the number with food allergy increased 12-fold, from 11 to 138 patients (and from 20.0% to 57.5% of children seen) The number with food anaphylaxis increased from five to 37 children (9.0% to 15.4%) over the same period. There were similar trends in age-adjusted Australian hospital admission rates for anaphylaxis in children aged 0-4 years, which increased from 39.3 to 193.8 per million population between the financial years 1993-94 and 2004-05, a substantially greater increase than for older age groups, or for the population as a whole (36.2 to 80.3 per million population).

CONCLUSIONS

There is an urgent need for coordinated systematic studies of the epidemiology of food allergy in Australia, to ascertain risk factors and guide public health policy. An increased prevalence of food allergy has implications for public health and medical workforce planning and availability of allergy services in Australia.