When rice-based formula is the right choice for cow’s milk allergy

By Dr. Liji Thomas, MDReviewed by Lauren HardakerApr 17 2026

A new expert-driven framework sheds light on when rice-based formula may be the better option for infants with cow’s milk allergy, helping clinicians navigate complex symptoms and family needs.

Study: The Role of Hydrolysed Rice Formula in the Dietary Management of Infants with Cow’s Milk Allergy: A UK Healthcare Perspective. Image credit: BaLL LunLa/Shutterstock.com

Cow’s milk allergy (CMA) is one of the most common in infancy, though it usually resolves by 3–5 years. Its symptoms impact both children and their caregivers, leading to the use of alternatives to cow’s milk. A concept paper in Nutrients reports expert consensus on the potential use of hydrolyzed rice formula (HRF) to support healthy growth and development in such children.

First-line formula options for infants with cow’s milk allergy

For infants with CMA who are not breastfed, the first-line option is extensively hydrolyzed cow’s milk-based formulas (eHFs) or hydrolyzed rice formulas (HRFs). If symptoms persist, careful elimination of other possible causes is required.

If none are identified, the symptoms may be due to residual peptides in eHFs, requiring an amino acid formula (AAF), though this is normally reserved for the most severe presentations, such as eosinophilic esophagitis.

Besides CMA, for which multiple international organizations recommend HRF or eHF, these are also suggested for use in anaphylaxis and food protein-induced enterocolitis syndrome, although guidance varies and caution is advised in some cases, such as rice-related FPIES. HRF has been used in Europe for over 20 years without reported adverse effects on infant health.

This paper reports on a decision tree designed to help identify situations that warrant HRF use in infants with CMA in the UK. “This decision tree is not intended as a replacement for current or future published official guidelines on CMA.”

In two UK expert meetings held in 2025, discussions centered on the current international guidelines for CMA, UK dietary management and prescribing practices, following which the decision tree was developed and refined. The aim of this tool is to help clinicians choose the right specialist formula rather than to guide the diagnosis or treatment of CMA.

Key clinical and family factors driving HRF selection

Five primary factors may influence the choice of formula towards HRF. These include persistence of symptoms despite multiple formula changes, which affect infant health and induce caregiver stress. Others include parental requests, driven by lifestyle or faith, that discourage the use of cow’s milk. Specialist recommendations should also guide clinical decisions.

Other secondary considerations that may influence the choice of HRF include potential sensitivity to traces of cow’s milk protein beta-lactoglobulin, faltering growth when intolerance to eHF is suspected, and the presence of multiple symptoms across organ systems. Note that AAF is often recommended in such cases. Parental preferences may also play a role, particularly when shaped by previous experience managing CMA in other children.

Infant acceptance is another factor, especially after six months of age, when eHF or AAF may be rejected due to their smell, texture, taste, and aftertaste associated with free amino acids.

In addition, HRF may offer potential microbiome-related benefits, as human monooligosaccharides (HMOs) are designed to support immune development, although their long-term clinical impact remains under investigation.

When HRF may not be appropriate or effective

AAF is a suggested second-line option when both eHF and HRF are ineffective at relieving symptoms and restoring adequate nutrition. Another line of thought is that if symptoms do not improve on HRF and cow’s milk is appropriately excluded from the diet, the child is unlikely to have CMA.

Children with the most severe presentations, such as eosinophilic esophagitis, or those with gut conditions not due to food allergies, such as short gut syndrome, are not good subjects for HRF trials.

Bridging guideline gaps with a practical clinical tool

This decision tree may help clarify situations in which HRF is preferred as the first-choice formula for non-breastfed infants. Its use should be seen in the context of limited evidence-based guidance on when HRF should be preferred. The possible choices reflect the accumulation of evidence and published international guidelines.

The main use of this tree is to address the gap in translating guidelines into clinical practice. This may be caused by parental pressure, infant preferences, persisting symptoms despite a few trials of eHF, and other psychosocial factors, as well as clinical observations.

Children in the UK with CMA would be more likely to receive optimal care with increased awareness of this condition and its management, and widespread education about its nature and available treatment approaches. HRF should also be made widely and equitably accessible to all segments of society, according to the authors.

Future long-term research should explore the impact of HRF on growth and immunity, as well as on the gut microbiome.

Overall, HRF represents an effective, well-tolerated, plant-based alternative that broadens the therapeutic options available to clinicians and supports a more personalized, family-centered approach to CMA management.

The authors note that further high-quality research is needed to strengthen the evidence base, particularly given that current recommendations are informed by expert consensus. The paper also discloses industry funding and potential conflicts of interest among contributors.

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