The Ultimate, No-Nonsense, Easy Guide to Infant Formula Substitutions

The Pediatric Insider

© 2022 Roy Benaroch, MD

Shortages of infant formula? Really? I’ll bet that wasn’t on your “Pandemic Surprise Bingo Card”. Fortunately, almost all families needing formula should be able to find good substitute formula brands that will help their babies grow and thrive. You just have to push past all of the marketing terms and crazy labels that have made formula purchasing such a confusing mess.

First: This guide is for the vast majority of healthy, term babies. If your child has a rare metabolic disorder or severe allergies, you need more specific advice from your physician. Babies who are born prematurely may also have more-specific needs, at least for the first few months – ask your doc. For the rest of you, here’s the steps to take:

• Read the label of whatever you’re using now. The ONLY words and phrases that are important are “Milk-Based”, “Hypoallergenic”, and “Soy”. Your formula will only have one of these words. IGNORE ALL of the other words on the label.
• Go to the store or visit your favorite online shopping site. You may have to go to more than one. Buy whatever formula you can find that matches the word you found in step (1).

Yes, you can substitute any “milk-based” for any other “milk-based”; you can substitute any “hypoallergenic” or any other “hypoallergenic”; you can substitute any “soy” for any other “soy.” And next time you need to buy more, you can do this again. You do not have to stay on one brand of formula – in fact, you never did. Advice to never switch was just marketing to preserve market share, loyalty, and profits.

More details below. But honestly, now you know what you need to know. Go shop. Don’t worry.

The details

Though most of human history, babies were nursed, usually by their moms, and sometimes by paid or enslaved wet nurses. Still, many babies didn’t get enough good-quality nutrition. When people say, “Well, what did babies do before formula?”, the answer is “They died.” I will not tolerate any mom-shaming or formula-shaming here.

By the mid-1800s it was clear that babies unable to nurse well had very high mortality, despite families trying to feed them a variety of paps and mashes and milks. These substitutes all difficult to digest and provided inadequate nutrition.

There are significant problems with using ordinary cow’s, goat’s, or other animal milk as a human milk substitute. Apart from issues of disease transmission and purity, the protein quality and quantities are wrong, and there are inadequate vitamins and minerals to ensure healthy growth. Modern commercial formula is hygienic and provides all of the nutrition a growing baby needs.

It’s also a huge business with big profits. There are only four major baby formula manufacturers in the USA, and tariffs and regulatory burdens have supported what’s close to a monopoly. Tight federal regulations require exact amounts of all of the important ingredients in all baby formulas. The only things the manufacturers can change are minor added ingredients and the marketing claims on the labels. Very few of those words actually mean anything important to the health of your baby – they’re there only to attract market share.

It’s a myth that there’s something special about individual brands of baby formula, and there’s never been a compelling medical reason that says babies shouldn’t switch formulas or try different brands. These recommendations created a “mystique” about the power of certain baby formulas, and made formulas seem like prescription medications. Parents, it’s implied, need a doctor’s advice to know which to buy. (I guess there’s some ironic truth to that – there are so many choices and words on the label that choosing formula seems overwhelming.)

Now: babies, especially young babies and newborns, do have fussy times, and they spit up, and their poops change character and color. All of that is often blamed on a choice of formula. But here’s a Pediatric Insider Secret – it’s probably not the formula. It’s just normal changes and normal fussiness. But if you change formula, say, every 5-7 days, eventually you’ll get lucky or your baby will outgrow a fussy phase, and you’ll have several good days in a row. Was it the new formula that fixed the problem? Probably not, but you (and your pediatrician) will be fooled into becoming a super-loyal customer.

And that’s a problem when shortages loom for so many formula brands. You’ve been hoodwinked into thinking your baby needs a specific brand. But guess what? She probably doesn’t care, and her health will be fine with any appropriate substitute.

Marketing words

Here’s a list of words I found on some packages of baby formula powder. None of them mean anything medically important. Ignore all of them. Don’t let them fool you or scare you.

2’FL HMO

All in One

Brain building

Breast milk, or “closest to breast milk”, or any variation on that

Clinically tested

Colostrum

Comfort

Crying/Reduces crying/Less crying

DHA

Easy to digest

Expert recommended

Fussiness

Gas

Gentle

HMO

Immune health/Immune support

Lactoferrin

MFGM

Neuropro

Non GMO

Sensitive

Soothe

Spit up

Supplementing

A few other marketing words deserve more explanation:

Antireflux. Many formulas claim, with no evidence, to be better for spit up or fussiness. But some take this a step further, adding modified rice starch that thickens in the acidic environment of the stomach to make the formula thicken. The idea is that it’s less likely to be spit up, and there is even a little bit of evidence that it sometimes works. But the vast majority of spitty babies don’t care if they spit up, and there’s no health consequences of spitting up. So for most babies on these formulas, it’s fine to use ordinary milk-based formula too.

European. Formulas manufactured in Europe, or formulas made to European standards in the US, have a sort of magic cachet in some communities. They’re more expensive, so they must be better. I guess. But it’s just marketing, again. There are no health benefits to European formulas. Use it if you want – it’s your money – but if you have to substitute during a shortage, any milk-based formula will do.

Lactose reduced, or low lactose, or lactose sensitive. Lots of kids, teenagers, and adults are lactose intolerant. Your baby is not. Human breast milk is loaded with lactose, and virtually all human babies digest lactose just fine. Removing lactose from formula is another a marketing trick.

Organic. If you can afford it, and if you can choose organic formula and other products, that’s fine. But don’t fool yourself. Organic foods are not grown “chemical free” or more “naturally” – they just use different, organic fertilizers and pesticides. I know of no good, compelling, or reliable evidence that organic baby formula or organic anything else is more healthful for anyone. BTW, same for the phrase “Non-GMO” – no health differences at all. Just marketing.

Partially hydrolyzed. Hydrolyzation is a chemical process that breaks down proteins into smaller strands. “Fully hydrolyzed” infant formulas are truly hypoallergenic, and are necessary for babies with true food allergies. But most babies who are thought to be “intolerant” of certain formulas don’t actually have allergies at all. “Partially hydrolyzed” formulas try to sort of imply that they’re partially-sorta-kinda friendlier for kids who might have kinda-allergies. But there’s no evidence that they make any real difference to anyone. Again, marketing.

Important words

Milk-based. Almost all commercial baby formula is based on cow’s milk, which is then modified to make it suitable for human babies. If your baby is doing well on a milk-based formula, choose a different milk-based formula if your favorite brand is in short supply.

Buried on the labels of baby formula are a handful of words that do have specific and important meanings:

Soy, or “plant-based.” Some commercial formulas use soybeans as a milk base. These provide good nutrition and are a reasonable choice for families who wish to avoid cow’s milk, or for the (rare) babies who are genuinely allergic to cow’s milk but can tolerate soy. If your baby is doing well on a soy formula, choose a different soy formula if you need to.

Hypoallergenic. These formulas are also based on cow’s milk, but the proteins are fully hydrolyzed or broken down chemically to reduce allergic reactions. These formulas aren’t needed very often, but if your baby is on a hypoallergenic formula, you should substitute with another hypoallergic formula. If you cannot find one, talk with your baby’s doctor – some babies can safely switch back to ordinary formula, but you need your doctor’s input for that.

Amino-acid based. These are rare, very expensive formulas for babies with severe allergies. If your baby is on one of these you’ll know it. Don’t make changes without speaking with your doctor.

Generics and store brands

Almost all “store brand” or generic formula in the US is manufactured by Perrigo, using the same standards for nutrition and hygiene as the better-known brands. There are no important differences. Any generic or store brand is fine, and has always been fine, whether or not there’s a shortage of the more-expensive products. Often, the color or style of packaging of generics is designed to look like a name-brand product, but don’t worry about the look and colors – all that matters are those three words. Is it Milk-Based? Is it Hypoallergenic? Is it Soy? The rest is fluff.

Things not to do

Don’t make your own formula at home. You don’t have the right ingredients or expertise. These will not provide good nutrition. Bad things can happen.

Don’t water down or otherwise try to “stretch out” commercial baby formula powder. Bad things can happen.

Don’t use “Toddler Formula” for babies less than a year. Honestly, there’s very little reason to use it for children past their first birthday, either.

Don’t panic buy or hoard. We saw this with toilet paper and sanitizer in the pandemic. There was always plenty of both, but panic buying cleared out the shelves.

Things you should do

Shop around. Help and share with neighbors. Stay involved with moms’ groups to find stores with stocked shelves. Ask your pediatrician for samples (we have some, but we’re running low.) If your baby has weaned and you have unopened, leftover powder, donate it to a neighbor or through your pediatrician.

Feed your baby age-appropriate solids & complementary foods starting at 4-6 months. By 9 months a lot of your baby’s healthy diet will be food, not formula or milk. Good!

Swap to ordinary milk at 12 months. You don’t need “toddler formula” or anything else special after the first birthday. I’m not even sure you need milk at all, but that’s a topic for another post.

Support moms who are nursing, and support moms who are using formula. Be kind. Always.

COVID in perspective: What we can all agree on

It’s not over yet. In some ways, we’re about back where we started, with a few key differences.  Delta is far more contagious. Kids are now catching COVID at ever-increasing rates, and pediatric hospitalizations are soaring. And we’ve got a safe and effective vaccine that’s saving thousands of lives – and could save many more.

For the latest studies, news, and statistics, check out my Facebook videos. Here, I want to focus more on things that I hope just about everyone can agree with. Starting on common ground might be a way to help us work together to keep each other safe.  

We need to appreciate & cultivate the people in healthcare more than the technology. There are no wonderdrugs for COVID, and it’s unlikely we’ll have one soon. What’s saving lives are nurses, techs, respiratory therapists, and physicians. We need more of them, and far more mental health resources too. Hospital beds and ventilators are not the bottleneck. We need to better invest in training and supporting the people we need to get through this.

Science shouldn’t be by press release and prepublications. Ordinary people & the press have not become accustomed to seeing sausage being made, and physician-scientists are coming across as waffling & inconsistent. Worse, many papers are being retracted – after wide media coverage. Poor studies are being weaponized and causing harm and mistrust.

Kids need a pause. We’re not yet able to provide a safe, effective learning experience in many communities. Let’s admit that, and stop pretending that children are learning the way they should. Unreasonable expectations are causing physical and mental illness among students and teachers. Give them a break. It’s not a race.

Let’s be honest about the length of this worldwide crisis. Things will not “get back to normal” soon.

Keeping people healthy and keeping the economy healthy are the same goals. Can’t have one without the other.

The “enemy” isn’t the other political party, or some other country, or people with whom you disagree. The “enemy” is a virus that doesn’t care what you think or what you believe. United we stand, divided we …. well, you know.

Lessons from the COVID-19 pandemic

We seem to be — finally! — crawling out of the mess of the COVID-19 pandemic, at least in the USA. Overall case loads and hospitalizations continue to drop, especially among vaccinated people and highly-vaccinated communities. There’s been a dramatic fall in COVID cases at my office, and people are becoming more comfortable getting out and getting together. It’s not over, but I think it’s fair to say we’re at the beginning of the end. While there’s still plenty to learn about COVID-19, some things have become clear. There are lessons we can learn to make our response to the the next public health crisis more successful.

Masks work. This wasn’t known at first, and mixed messaging slowed uptake and left some lingering doubts. But the science is clear: masks help limit the spread of respiratory infections like COVID-19. No, they’re not perfect. No, they’re not the only way, or the best way, to stop a pandemic. But they’re a safe and useful tool as part of a public health response.

Lockdowns are a mixed bag. Lockdowns did help limit the spread of COVID, or at least slowed it down, especially in the initial phases of the pandemic. But there were — and still are — significant drawbacks. Economic hardship caused difficulty in access and the affordability of health care and child care, and social isolation was a tremendous hardship especially for older people. Closing schools for months on end was a disaster for many children, especially the most vulnerable. Lockdowns may be needed in the future, but they should be done with great care, targeting small areas only when necessary.

Evidence changes. This can be a tough one to swallow. But just because scientists were mistaken about certain things doesn’t mean they were wrong. Evidence changes as we learn more, and our advice and conclusions have to change too. Some examples: initial evidence led some well-meaning physicians to advise using hydroxychloroquine to treat COVID, or to focus on scrubbing and disinfecting surfaces to prevent COVID’s spread. Better, later evidence showed this advice was wrong, and the advice needed to change. Too many people focused on picking teams and trying to prove that they were right instead of following the best evidence as it accumulated.

mRNA vaccines rock. mRNA-based technology had been in development for decades, but the speed at which it was repurposed for massive vaccine development programs was astounding. Inventing incredibly effective and safe vaccines against COVID, literally in the span of a few months, will be remembered as one of history’s greatest public health triumphs. That same technology is already being used to develop vaccines against HIV and improved influenza vaccines, and powerful treatments for cancer and other diseases.

Inequities are magnified in a crisis. The disparate impact of COVID and its complications on people of color and economically disadvantaged neighborhoods is a tragedy and a national shame. School closures, shuttered businesses, and a lack of health care access fueled a nightmare that hit the most vulnerable the hardest. We must do better.

Public health messaging is difficult but crucial. In a time of crisis and uncertainty, it’s especially important for public health leaders to reach out with information that’s clear and practical. It’s a crowded public space, with entertainers, politicians, scientists, and community leaders all clambering to have their voices heard. Sometimes it seemed like the people with the worst advice were heard the loudest, leading to confusion and unnecessary worry. Amplifying sanity is a necessary part of a crisis response.

This will not be the last worldwide public health crisis – it’s going to happen again, maybe with an infection that’s even more transmissible than COVID-19. We’ve got lessons to learn from our response to this pandemic. I know: we’re tired, and we’d love to move on. But we need to step back and study what happened so we can do better next time. I don’t mean fingerpointing — there’s plenty of that already. But a genuine, sincere, and objective look at what we’ve learned is the best way to prepare for next time.

The Ultimate Baby Book for New Dads – my new book, out soon

Hey hey! I’ve got a new book coming out next month, to be released 6/22: The Ultimate Baby Book for New Dads: 100 Ways to Care for Your Baby in Their First Year. It’s a lighthearted “how to” guide for the first year of Dadhood.

This was a whole lot of fun to write, and became my “COVID, but not COVID” project for the year. I’ve been plenty busy dealing with the pandemic, making videos, and taking care of my patients, but I was looking for something worthwhile that could take my mind in a completely different direction. And the Ultimate Baby Book for New Dads was born.

By the way, the book is honestly not all about dads — not even close. Most of it would work great for moms too. But it looked to me that there were plenty of family- and mom-oriented books out there, and the few books that focused on dads were more joke-books than genuinely helpful books. My book isn’t about “Haha look how dumb men are”. It’s about dads who really want to be part of raising a baby. Read it, you’ll love it!

You can preorder it now on Amazon, or just check out the book’s page for more details. You’ll probably want to order several copies, in case your first copy gets worn out, or something. Makes a great gift for soon-to-be Dads and parents, too!

Visit RoyBenaroch.com for a more-complete list of my books, other media, and apocrypha. Thanks!

Visit Covid Pathway for clear instructions to guide your way

Hey insiders! It’s been quiet around here, I know. But I’ve been busy!

Visit CovidPathway.com for my new site, with clear instructions for all of us to follow. We can beat this thing back, but we need to all do our part — and here’s where you’ll find clear, friendly instructions. Have you been exposed to COVID? Do you have COVID symptoms? What are the best things we can do to protect ourselves, our families, and our communities? You’ll also find a collection of my COVID-themed videos — yes, there’s a voice and a face behind this blog! Check it out and let me know what you think!

In other news, I’m finishing up a sequel to my award-winning* Audible course, Medical Mysteries Across History. Stuck at home, staring at the walls, trying not to catch The Rona? My courses on Audible and The Great Courses or The Great Courses Plus (subscription service) are guaranteed** fun!

The Pediatric Insider isn’t ready for mothballs yet — I haven’t much time for my blog lately, but I’ll be back. Feel free to send in suggestion and keep commenting. Thanks everyone for your support!

* Well, not literally. Who gives awards for these things, anyway?

** I’m pretty sure if you buy or subscribe to these through The Great Courses, there’s a 100% money back guarantee. But I don’t guarantee that. See what I did there? Haha! No, seriously, they will give you your money back if you ask.

Nurturing your children at home: Tips for sheltering in place

The Pediatric Insider

© 2020 Roy Benaroch, MD

These are difficult times, and there’s a lot of uncertainty about what will happen next. When will our kids go back to school, and when will parents be able to return to their routines? There’s a lot we don’t know, But there are things you can do now to help you and your children stay well while staying at home.

Stay with a routine. Get up and go to bed at reasonable times, and block out time for school, play, and meals.

Get outside. We all need to avoid crowds, but that doesn’t mean you and your kids must stay indoors. Go for a bike ride. Draw a colossal, life-sized squid on the cul-de-sac. Take your dog for a walk. Everyone needs movement and exercise, every day. It doesn’t have to be in a gym.

Play with your kids. Foosball, Super Mario World on an old SNES, ping pong, Gin Rummy. Or make a game – create an obstacle course, or use paper towel rolls taped to the wall to create a ball-maze. Draw and dance and create together.

Connect with friends and relatives with Zoom, Facetime, or whatever. We’re supposed to be physically distant, but we’ve got the technology to stay socially together. Not ideal, but better than nothing!

Be gentle, and be kind – with yourself, with your kids, and with everyone else you meet. We’re stressed and life is strange, and that doesn’t always bring out the best in ourselves or our neighbors. Pay back negativity with kindness; or if that doesn’t work, ignore it. We all need more humor and positive vibes these days. If you or your kids aren’t getting that from certain friends, it’s time to “mute” them. (The friends, not your kids.)

Lower your expectations. You probably didn’t sign up to home-school your kids, and you’re maybe not going to be able to sustain the kind of job you wished you could do. (Hey, maybe we’ll all learn to appreciate our kids’ teachers more!) You may be discouraged that there’s a pile of laundry, or that you’re not getting enough stuff done every day. This is a whole new ball game, and failing at your expectations probably means your expectations were off-base – not that you’re a failure.

Help people. You’ll feel better (and you’ll set a great example for your kids) if you do simple things to help your neighbors. Send post cards. Deliver cookies (leave them at my door!) Offer to pick up someone’s medicine, or make a huge batch of chili to share. Look out for examples of people helping people – there are thousands of these stories on social media every day, though sometimes they’re lost in the clutter.

Speaking of social media: it’s a great way to connect and get news, but you’ve got to turn in off sometimes. There’s too much bad news, incorrect news, and hysteria to stomach for long. Consider putting guard rails up for yourself and your children – only, say, 1 hour of Facebook, once a day, then you are done. When you do post and share, post reliable things from credible sources. Even better, share silly things that will make your kids and your friends laugh.

Things will get better. In the meantime, we can make the best of our shut-in time. And, by the way, my favorite cookies are chocolate chip.

Getting care quickly improves concussion recovery

The Pediatric Insider

© 2020 Roy Benaroch, MD

Concussions are a mild traumatic brain injury. Mild means you can’t see any damage on a CT or MRI scan – but’s still an injury, and injured brains take time to recover. Symptoms like headache, brain fog, and trouble with mood, memory, and balance last on average 3 weeks in sports-injured teens. Three weeks is bad enough, but we know some teens have symptoms that linger far longer.

A new study from JAMA Neurology found an important predictor of a longer recovery: just how long did it take for a teenager with a concussion to get a medical evaluation and treatment? About 250 teens and young adults, aged 12-22, who had a sport-related concussion were tracked to see how long their symptoms lasted. The researchers looked back on many factors to see what best predicted longer symptoms. Many things you might think would be predictive were not, like measures of concussion severity or the findings of neurocognitive testing. These didn’t seem to matter.

The best predictor was a simple measure of how long it took to get in for an evaluation. If that first clinic visit took more than seven days, there was a six-fold increase in the chance of having symptoms lasting more than a month.

The treatment of concussion is actually pretty simple, but it is important. The first, most-important rule is to get people with suspected concussions off the field. They should absolutely not continue play. After the initial evaluation, they’ll need to reduce sports and academics, and slowly ramp back up to full activity as symptoms improve. Patients with concussions should not avoid all activity, though – some light exercise is ok, and can help recovery if done carefully. That’s why that initial medical evaluation is important, and should be done quickly. Patients and families need clear guidance on what to do, and what to expect from their recovery.

 

More about concussions:

What is a concussion?

What to do when your child has a concussion

Football helmets do not protect your child’s brain

The holiday un-gift guide: What not to buy this season

The Pediatric Insider

© 2019 Roy Benaroch, MD

Ho ho ho! It’s time for my nearly-every-yearly, not-too-clickbaity, almost-useful holiday gift guide with a twist! Plenty of guides tell you stuff you should buy. We’re here to save you money, and maybe even save your child’s life. Here’s a bunch of things you really shouldn’t buy this holiday season.

 

Baby walkers

Gizmos like this are a terrible thing to buy for a baby or family. Walkers slow infant development by making it more difficult for your baby to learn to walk. And, bonus, they injure about 9,000 babies a year in the USA. The AAP has called for banning them. Please, just don’t buy one of these things, m’kay?

Instead, consider a push-behind device or something like a standing activity center. They’re fun, provide genuine help with motor skills, and won’t maim or kill your baby!

 

Tiny magnet toys

Even the manufacturers of these toys, consisting of dozens or hundreds of little magnets, know they’re unsafe. But they still send mixed messages on their product listings. This one says it’s for ages 14 and up – “Use under adult supervision only” – right underneath where it says “GREAT GIFT FOR YOUNG AND OLD.”

What’s the problem? Little kids love to swallow these. And clumps stick together in the gut, causing necrosis (dead gut tissue.) Kids who swallow these are rushed to the OR, pronto. Before and after photos, courtesy of my friend and pediatric GI specialist, Dr. Tejas Mehta:

 

Baby sleep positioners

These are completely unnecessary, and can kill your baby. Other than that, sure, they’re fine. No, seriously, do not use a gizmo to position your baby in sleep. Seriously. Death. Bad. Ok?

 

Toy Vacuum Cleaners

Everyone likes to vacuum, right? And it’s not that toy vacuums like this one ($43) are dangerous. But you can buy a REAL ONE for $35. You have a kid wants to vacuum? Get him a real vacuum and put him to work!

 

Baby Bum Brush

You can use this to spread diaper cream on your baby’s bottom. Or this. Or this. Or your fingers, like God intended.

 

Amber Teething Necklaces

These are both a choking hazard and a strangulation hazard – especially ones that proclaim “The screw clasp prevents your baby from taking the teething necklace off.” That also means if the necklace gets caught on something, rather than breaking at the clasp it can strangle your baby. Or, if they do break apart, each individual bead becomes a choking hazard. And, besides, there’s no evidence whatsoever that these things relieve any symptoms of teething at all.

 

Crib Bumpers and Pillows

Babies should sleep on a firm, flat surface, NOT near soft squishy things that can interfere with their safe sleep. Squashy soft pillowy things are not only unnecessary, they kill babies. The AAP has been calling for them to be banned for years. I can’t even look at that photo without cringing.

 

Food Sensitivity Tests

Give the gift of paranoia! IgG-based food sensitivity tests, widely advertised on platforms like Facebook, are absolutely worthless. They measure an antibody response that shows you’ve eaten the food, not that you’re allergic or sensitive to the food. These tests don’t predict allergy or sensitivity or anything else. They just make people worry and encourage eating disorders and orthorexia.

 

Measles

Just don’t. There’s a very safe and very effective vaccine that had stopped measles transmission almost entirely in the US, Europe, and many other areas of the world. Now, thanks to the lies and distortions from antivaccine groups and Russian trolls, it’s surging back. That so many wealthy and privileged people are “helping” bring measles back to both the US and to developing countries is despicable. Be safe. Protect your children, your family, and your neighborhoods – even those too ill or young to be vaccinated. Make sure you and your children are protected, safe, and immunized.

What do current guidelines say about treating allergies with Benadryl?

The Pediatric Insider

© 2017 Roy Benaroch, MD

Last week, I published an essay titled Goodbye, Benadryl – It is time for you to retire. It generated, to use a precise term, a butt-ton of comments, almost all of which vehemently disagreed with my assertion that Benadryl is neither the safest nor most effective choice for most allergic symptoms. Here, I’ve revised the topic, looking at the most-recent published guidelines on the topic of allergies and their treatment.

Executive summary (tl; dr)

A large number of well-documented, authoritative guidelines on the treatment of allergic rhinitis and urticaria call for the use of newer antihistamines for the first line treatment of these common manifestations of allergic disease. Benadryl (diphenhydramine) is no longer recommended as first-line treatment because it works more slowly, is less effective, and is less safe. Benadryl may be useful for other conditions, but it should not be considered the first line therapy for most common allergic diseases.

 

Introduction

A Pubmed search was undertaken to find current guidelines from national or international health organizations on the treatment of allergic rhinitis and urticaria. These two diseases were chosen because they are by far the most common allergic indications for the use of diphenhydramine. I included guidelines I could find that focused on children and/or adults, mostly from 2015 and later.

The most definitive statement on the recommended use of antihistamines from these guidelines will be reported. Interested parties are encouraged to review the links for supporting documentation – these guidelines often have hundreds of references, and I’m not going to reproduce them here. Some passages will be bolded for emphasis.

In these reports, “second-generation” and “newer, non-sedating” antihistamines typically include cetirizine, loratadine, and fexofenadine; they may also include other agents that are less widely used here. “Older”, “first-generation”, or similar terms typically refer to diphenhydramine, chlorpheniramine, and other products.

 

Guidelines for the treatment of allergic rhinitis (“hay fever”)

From Clinical Practice Guideline: Allergic Rhinitis from Otolaryngology-Head and Neck Surgery (2015): “The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching.”

From International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (2018): “The AAO‐HNS concluded, based upon RCTs and a preponderance of benefit over harm, a “strong recommendation” for the use of newer‐generation oral H1 antihistamines for patients with AR….a favorable risk‐benefit ratio was determined for using newer‐generation oral H1 antihistamines over first‐generation oral antihistamines.1170 The evidence was further strengthened with several meta‐analyses of the current data, where accurate and robust effect estimations can be derived from a large population1171.

From Allergic Rhinitis, published as part of a series “Practical guide for allergy and immunology in Canada 2018”: “Second-generation oral antihistamines and intranasal corticosteroids are the mainstay of treatment.”

From Treatment of Seasonal Allergic Rhinitis: An evidence-based focused 2017 guideline update: “Antihistamines are available as oral (first- and second-generation) and intranasal preparations. First-generation antihistamines (eg, diphenhydramine, chlorpheniramine, and hydroxyzine) cross the blood-brain barrier easily and bind central H1-receptors abundantly, which can cause sedation. They also lack specificity because cross-binding also occurs with cholinergic, a-adrenergic, and serotonergic receptors, which can cause dry mouth, dry eyes, urinary retention, constipation, and tachycardia.18 Cumulative use of first-generation antihistamines with strong anticholinergic properties has been associated with higher risk of dementia.19 In contrast, second generation antihistamines (eg, fexofenadine, cetirizine, levocetirizine, loratadine, desloratadine, ebastine, epinastine, and bilastine) are more specific for peripheral H1-receptors and have limited penetration of the blood-brain barrier, thus reducing sedation.”

From Allergic Rhinitis, a clinical guideline from the American Academy of Family Physicians (2015): “Oral second-generation/less sedating antihistamines should be prescribed for patients with AR and primary complaints of sneezing and itching.”

It is clear that every major guideline for the treatment of AR prefers newer antihistamines over diphenhydramine. None of these agents, though, are as effective as other agents such as inhaled corticosteroids.

 

Guidelines for the treatment of urticaria (hives)

From BSACI guideline for the management of chronic urticaria and angioedema (2015): “Pharmacological treatment should be started with a standard dose of a non‐sedating H1‐antihistamine (grade of recommendation = A).”

From Clinical practice guideline for diagnosis and management of urticaria (2016) “With regard to side effects, EAACI/GA2LEN/DEF/WAO Guideline 2013 recommends the use of first-generation (sedating) -antihistamines only when second-generation non-sedating antihistamines are not available.”

From Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults – Brazilian Society of Dermatology (2019): “Oral antihistamines are key drugs in the treatment of chronic urticaria, especially nonsedating and low-sedating agents… According to the Urticaria International Guideline, as second-line of treatment, use of up to fourfold doses of second-generation antihistamines is indicated, whenever licensed dose failed to control the disease. 4,5 The use of these drugs at maximum doses, such as desloratadine 20 mg/day, levocetirizine 20 mg/day, loratadine 40 mg/day, and cetirizine 40 mg/day, is not yet approved in Brazil, despite published international scientific literature.”

From Management of chronic urticaria in children: a clinical guideline, Italian Journal of Pediatrics (2019): “Question 20. What is the drug of choice for CU? Recommendation. Second-generation H1-antihistamines are the first-choice treatment for CU (Level of evidence I. Strength of recommendation B).”

The overwhelming consensus from multiple international guidelines supports the use of newer antihistamines over older agents.

 

Guidelines on the use of antihistamines

From CSACI position statement: Newer generation H1-antihistamines are safer than first-generation H1-antihistamines and should be the first-line antihistamines for the treatment of allergic rhinitis and urticaria (2019): “The Canadian Society of Allergy Clinical Immunology (CSACI) recommends that newer generation AHs should be preferred over first-generation AHs for the treatment of allergic rhino-conjunctivitis and urticaria.” This article summarized in a media account, here.

In addition, an extensive review from 2010 concluded, “This review raises the issue of better consumer protection by recommending that older first‐generation H1‐antihistamines should no longer be available over‐the‐counter as prescription‐free drugs for self‐medication of allergic and other diseases now that newer second‐ generation nonsedating H1‐antihistamines with superior risk/benefit ratios are widely available at competitive prices.”

 

Conclusion

Benadryl (diphenhydramine) and other older or first-generation antihistamines should not be considered first line therapy for urticaria or allergic rhinitis.

 

Caveats

There are certainly other uses of diphenhydramine, as an agent to treat extrapyramidal side effects and perhaps as a mild sedative. It can also be used to treat motion sickness and nausea. Evidence for its usefulness for nonspecific cough and cold symptoms is lacking, though it’s often included in multi-symptom “cold relief” medications. These should not be used under age 4, and should have a limited role in reducing symptoms in older children and adults as well.

Diphenhydramine is among the only antihistamines available for parenteral use, which can be uniquely advantageous in limited circumstances where use of an oral agent is not possible.

Though often used in a setting of serious allergic reactions, anaphylaxis should always be treated with epinephrine, not an antihistamine. Antihistamines can be considered adjunctive therapy for these reactions, but epinephrine should never be delayed while giving an antihistamine or awaiting a response to an antihistamine.

from https://www.brainyquote.com/quotes/david_hume_379427

Goodbye, Benadryl – it is time for you to retire

This has become, by far, the most-discussed and most-hated post that I’ve ever written. In retrospect I should have been much more explicit: I’m talking here about using Benadryl as an antihistamine to treat allergic disease. A follow-up post includes about 10 links to well-supported, recent guidelines that support my contention that Benadryl is not a good choice to treat allergic disease. Newer agents are faster, more effective, and safer. 

 

The Pediatric Insider

© 2019 Roy Benaroch, MD

Sometimes, old ideas and time-tested treatments remain the best. Newer doesn’t always mean better. Except, in the case of tried-and-true Benadryl. It is time for that old drug to be retired, sent off to pasture, and never used again. Goodbye, Benadryl. Fare thee well, adieu, and don’t let the door hit you on the way out.

Benadryl (diphenhydramine) was introduced in 1946. The top single that year was Perry Como’s “Prisoner of Love,” and, with all due respect, neither has aged well. Back in 1946, medicines like Benadryl didn’t have to pass the stringent safety and efficacy standards now required. And there’s zero chance, today, it would every have been approved for over-the-counter sale – and even if it made it as a prescription medicine, it would be plastered with warning labels.

tl;dr: Newer & better alternatives to treating any allergic disease are cetirizine (Zyrtec), loratadine (Claritin), and fexofenadine (Allegra). These are all safer, faster, and more effective. There is no situation where Benadryl is a better choice as an oral medication. No one should be using Benadryl for anything.

 

Benadryl isn’t safe

Benadryl causes significant sedation. One study in a driving simulator showed an ordinary adult dose of Benadryl caused worse driving than a blood alcohol level of 0.1% (that’s fairly drunk, probably between buzzed-drunk and frat-party drunk). Ordinary doses of Benadryl can also commonly cause urinary retention, dizziness, trouble with coordination, dry mouth, blurry vision, and constipation.

But more importantly, in an overdose Benadryl becomes very dangerous. It has caused respiratory depression, coma, heart arrythmias, and death in children and adults, and in doses that aren’t super-high. This is not safe stuff to have in the house with an exploring toddler, or in a teenager who might help themselves to whatever is in the medicine cabinet.

 

Newer alternatives are much safer

In the 1980’s, newer-generation antihistamines were introduced. At first, they required a prescription and were crazy-expensive; now, the best of these are cheap, generic, and easily available OTC.

These medicines were developed to address the serious safety concerns of Benadryl and other older antihistamines. They do not cross the “blood brain barrier”, cause minimal if any sedation, and don’t cause nearly as many of the other side effects. And, bonus, they’re not very dangerous even in massive overdoses. A recent review quoted that there has never been a death even in instances of up to 30 times the recommended dosing.

 

Newer alternatives are more effective, act more quickly, and last longer

In a serious allergic reaction, we want a treatment that’s quick and effective. Keep in mind that in the case of anaphylaxis, the most serious allergic reaction, antihistamines are NOT the correct, first-line treatment. Anyone experiencing an anaphylactic reaction, which can include a loss of consciousness, trouble breathing, and widespread hives and flushing, should immediate and without hesitation be given epinephrine by injection. Epinephrine should never be delayed while looking for or preparing an antihistamine. Antihistamines do not save lives. Epinephrine does. Keep your eye on the ball.

But for more-mild allergic reactions, like simple hives, an antihistamine is a good idea. And some docs still prefer Benadryl, since it’s been around forever. But the newer drugs are much more effective. They begin working more quickly, they are more effective at controlling symptoms, and they last much longer – so symptoms are less likely to return. And, bonus, since side effects are minimal, doctors can safely prescribe regimens even up to four times the labeled doses for specific indications (this has been studied extensively). For routine use, follow the label instructions – talk to your doctor if that’s not working, or if you think a higher dose is needed.

 

Benadryl and its generics (diphenhydramine and many combo meds) are still very popular sellers, and many docs and nurses still recommended it. This is just out of habit and inertia – there is no good reason, under any circumstances, where Benadryl is the right choice when an oral antihistamine is needed. It’s not 1946. It’s time for Benadryl to be permanently taken off the market and relegated to the history books.