Starting an Elemental (Amino Acid) Formula
Sarah Camp, February 2021
Click here to be taken to our main formula overview page! Additionally, please know that you do NOT have to switch from breastfeeding to an elemental formula (or any formula period) just because a doctor recommends it to you! You CAN continue giving your baby breast milk as long as you are willing and able to work on dietary modifications until you find a diet that your Gerdling is able to tolerate. This may mean eliminating more than just milk and soy. These resources are a good starting point to what help you may need to be able to continue breastfeeding if desired.
“It may get worse before it gets better.”
Unfortunately this is a pretty common theme when it comes to the treatment of reflux. Progress doesn’t usually look like a steady straight line going in the upward direction; it’s more often than not a zig-zagging roller coaster with a few loops involved that ends up at a higher (better) point than it started.
When tongue/lip/buccal ties are revised, there will be pain involved with the procedure and stretches before any improvements are noted.
Transitioning to a new formula, *especially* an amino acid one, is no different.
When transitioning onto an elemental formula (such as Neocate, Elecare, Puramino or Alfamino), Baby’s symptoms can (and probably will) worsen at least somewhat before they improve.
Think about it like when you’ve had an injury…a cut, scrape, burn, anything like that. As the wound heals, there is discomfort involved! It may itch or even continue to be painful as the skin underneath regenerates. Likewise with an elemental formula, there is *healing* involved. Baby’s gut may not actually be “itching,” but as the healing in the GI tract occurs, some discomfort is definitely normal.
Poop will almost certainly get worse and change multiple times throughout the trial period. This happens as the body is ridding itself of any “offending” proteins, as well as repairing damage in the GI tract. Remember that the “countdown” on the trial does not officially begin until baby is *fully* on the new formula, and a trial period can actually take longer if the transition was fast or even cold-turkey. [See bottom of this post for an example poop photo.] It will likely take six weeks fully on the elemental formula to decide whether it is a pass or fail.
Remember, you can always visit THE Poop Post to check how your transition is going or how the formula is being tolerated!
Reflux may increase as well. This is not only due to the healing going on, but also because elemental formulas are simply thinner than their counterparts. The best thing that can be done to counteract this is to make sure acid production is well-controlled with a properly dosed PPI (*not* thickening without medical necessity as indicated by a swallow study and under the supervision of a Speech Language Pathologist.)
The potential for increased GI upset is one of the major reasons that we strongly encourage you to consider a very slow transition onto an elemental formula. The chart below shows how to transition from a “regular” or even extensively hydrolyzed formula onto an amino acid formula.
A gradual transition also helps baby get used to the very…unique…taste that elemental formulas have. Even so, taste can still be a major challenge to overcome, especially the older a child gets. Taste usually isn’t as much of an issue for young infants. This post by Nutricia Neocate explains why: https://www.neocate.com/living-with-food-allergies-blog/understanding-infant-taste-buds-work.
For babies who truly struggle with accepting the taste of an elemental, some parents have found that flavoring, at least temporarily, may be necessary. The screenshot below gives an example of one way to flavor elemental formulas with simple syrup (equal parts sugar + water) and alcohol-free vanilla extract.
Alcohol-free vanilla extract: Shop HERE
Another thing that causes concern for many parents when starting an elemental formula is a drop in ounces per day intake. As long as baby is making plenty of wet diapers and gaining weight, this should not be a major concern.
Jaclyn D. writes: Basically, the sole purpose of Neocate is not nutritional. It’s healing. Nutrition is actually a bonus here, lol. Basically, it’s jam packed with all kinds of good stuff. Babies will get fuller faster. This is why I ALWAYS tell moms to ignore what they think babies should be drinking in oz per day. This is totally irrelevant to elementals.
Click here to be taken to our forum discussion: Misconceptions about Neocate & Elecare.
We get it, it’s scary! When you’ve gotten baby feeling better, you don’t want to feel like you are moving backward. You don’t want to see your child in any discomfort. You’re also (understandably) hyper-sensitive about watching for reactions, and it can be really hard to tell the difference between what’s normal and what would be considered an immediate fail for the formula.
Signs that the formula isn’t going to be tolerated and that the trial/transition should end early would be:
- Increased or new visible blood in stools
- New/spreading/swelling rash
If at all possible, especially if a baby is younger than 12 months, consider stopping solids altogether while in transition and during the trial period. This will eliminate a LOT of variable factors in determining whether the new formula is being tolerated or not. If this is not possible (especially if baby is 18+ months), then try to go down to as few foods as you possibly can that you know are safe/passes.
One of the BEST types of encouragement an anxious parent can get is hearing from someone else who has already walked down this path and made it to the other side with a happier, healthier baby.
Kristina B. writes: For My first it took whole 6 weeks to see the full effect. This was from normal formula to Neocate. Eczema disappeared after a few days though. With my second we went from breastfeeding to Neocate very slowly but saw the difference much quicker! It was a matter of days she slept better but all took a few weeks to fully settle. I flavoured with vanilla for a few days then reduced the flavouring gradually, it worked well.
Jasmin R. writes: I want to start by saying we are doing great now!! We switched to Neocate after being on Alimentum and testing positive for blood in stool (after going from regular, to gentle to Alimentum. I pushed for all formula changes bc the drs kept saying nothing was wrong and her stools were fine. I also pushed, thanks to this group, for her stools to be tested) The transition period was super frustrating. Symptoms definitely got worse before they got better. Although reflux symptoms had basically been gone prior to starting Neocate, my little one began spitting up like a machine again during the transition period. The choking (occasionally) also came back. Her stool looked great one day then awful the next. I would say after about two weeks fully on Neocate we started to see improvement. Within 4-6 weeks everything balanced. My little one is now happy, healthy and thriving. All reflux symptoms have subsided and stools look great. Last two stools tested negative for blood . We did transition a little faster than the group recommended as that seemed to work well for baby and us. Her skin was so bad and was requiring steroids so we were more eager to transition to see if it helped as well – it did. #success #tolddr
Katie H. asked: Jasmin, Hey there! Can I ask what the biggest reason you moved from Ali to Neocate? We’ve got pain controlled by compounding the Omeprazole but her poop is mucousy, she has itchy eyes, sneezes, and still spitting up mass amounts. Actually that piece is peaking. I keep putting off switching to Neocate or Elecare bc the spit up right now is our biggest symptom I would say and I feel like Neocate will increase that. I’ve been wavering on this decision for 6 weeks now.
Jasmin R. replied: Katie, it was not an easy choice. The biggest reason I switched was due to her symptoms. Although her reflux had decreased significantly on Alimentum it was starting to increase again. Her skin was so rashy and nothing we did was helping. I felt from the beginning the root cause of her reflux was an allergy/intolerance. I kept pushing for them to test her stool and when they finally agreed and there was blood present that was it for me. Her reflux did get worse at the beginning of the transition, but is now gone completely. No more mucousy stools and her skin has improved significantly! It really came down to her health and comfort. I am not a dr but with the symptoms you are sharing sound like an allergy/intolerance. If you are not seeing improvement with meds something isn’t right.
Marisa L. asked: Jasmin, Did your LO’s poop get wayyy more mucousy on Neocate and did they get diaper rash? I’m on day 3 of trialing. His symptoms are much worse and I’m wondering if I should continue pushing through.
Jasmin R. replied: Marisa, it got worse, then better, then worse then leveled at much better! The diaper rash definitely got bad, but her skin was so rashy and sensitive before it was hard to tell if it was the Neocate that caused it. I will find the link that was shared with me here about elemental formulas. It takes time for the healing to occur and at least in my case symptoms got worse before they got better. We switched gradually (a little quicker than the group recommended bc it worked for us) it took a few weeks to really see a difference; and it was so hard when things initially got worse. In the end it was worth it. Hang in there mama! I will find the link on my intro post and share with you.
Angelique A. writes: My LO started the transition to Neocate before she turned 3 months old. I went very slowly and she seemed to get stuck when we were at a 1:1 ratio with Neocate. I remember reaching out for a week with an SOS because she was miserable. I felt like she was stuck in the transition because anytime I upped the Neocate her symptoms were worse. Sleep suffered, hard gas, screaming and arching. She was an exorcist during feedings and trying to put her down took hours.
I have to say though, I started home compounding 2 weeks into the transition so at day 5 of the PPI, is when her reflux exacerbated. About 2 weeks later and after switching to Neocate 100%, reflux symptoms diminished greatly.
So I had a Neocate transition and acid battle at the same time.
Sarah and Laura told me to push through and I read all the stories of parents who went through something similar and so I pushed through. My husband hated me making her medicine and my mom didn’t understand or agree, but WE MADE IT THROUGH.
Once we got her on the right dose, I had a happy baby.
She doesn’t eat as much as the books and Ped say she should be. I get maybe 16-20oz in her, but eating less on elemental formula is normal and she is gaining weight so we are all happy.
This road took many months filled with pain and suffering and lack of sleep and now she’s 7.5 mos and she sleeps appropriately and smiles. We have our hiccups here an there as she started teething, but we know it will pass.
Rachelle M. writes: We are on day 7 of Neocate and it’s been amazing. No severe gerd anymore! I’m in awe thank you.
I was certain corn was an issue bc of all the things he’s failed but I’m now questioning soy.
His last formula still had small amount of milk and soy and was still causing issues.
Perwana H. writes: We were on SO many different formulas for baby’s suspected MSPI. We ended up also trying Alimentum RTF for maybe 2 days before baby started seemingly having swollen eyes and face, at nighttime of all times . I was frantic because of course I was afraid of an anaphylactic reaction, especially possibly overnight. With the advice of the great women of this group, I decided to switch her cold turkey to Neocate. She had a good few days of miserable reflux, I honestly can’t remember how many days because her younger infancy days are mostly a blur now , but it really did get a lot WORSE before it got better. I thought I had made a bad decision. She would refuse to drink it… and reflux then choke on her spit up. I’d try for hours to feed her so she could get her calories in, and I feel like she developed a minor bottle aversion. She also couldn’t lay flat, she would be uncomfortable. BUT… after that cold turkey switch period, everything subsided and she’s been on Neocate since! She’s almost 8 months old and tolerating it well. She’s off meds, can lay flat and just has minor reflux that’s manageable just because Neocate is ridiculously thin!
The following examples are copied and pasted from moms’ comments on their babies’ transition onto an elemental formula. Sometimes it helps to hear from someone else who has walked through this…it can be very rough, but is so reassuring to know someone else has been there before & come out better on the other side!
June 26: We are on day 2 [of gradual transition] and just a bit of gas at this point.
July 11: We are doing a slow transition (as suggested by this group) but baby has started barfing up his bottle post feed again. He hadn’t done this for about 6 weeks prior to the switch. Now that we are at 75% Neocate and 25% Ali rtf, he seems to have a hard time keeping it down…Sucks because he actually seems worse on this than the Ali rtf at this point. I’m just going to go slow and continue to give his body time to adjust…Eating a bit less and fussy. Up last night crying after his dream feed which is very unlike him. No signs of teething…Doesn’t seem to be pain from acid more so tummy pain/gas. I’ll keep going and hope he adjusts.
July 18: Baby is refusing his dream feed even when we try for later at night. He doesn’t seem in pain, some slight discomfort from gas but all in all he’s in good spirits. His refusal to feed at night drops his daily intake from around 30-32oz to 25oz. He’s 8months and 18lb 10oz taking only formula at this point. This is the least he’s ever eaten and he won’t take more during his wake hours (if I offer more frequently he eats less per sitting and pushing for more each sitting often leads to him vomiting his bottle).
July 24: He’s getting 5oz Neocate in a 5.5oz bottle so we are almost full Neocate at this point. Poop is the right dark green colour but still lots of shiny mucous. I know it takes times for the body to heal so we will just keep going!
July 26: Can I have a poop check? This is still pretty shiny and mucousy right? We are one week into full a Neocate. Little dude is in good spirits, sleeping like a champ, and I’ve decreased his meds slightly. Poop still isn’t there but it’s early.
July 27: Should I be concerned if the mucous increases during the trial period? We are just over one week on full Neocate and he had some full globs of mucous in his last diaper. One of the worst diapers I’ve seen. He’s in good spirits and no changes in appetite/sleep.
Aug 12: (a little over 3 weeks on Neocate): *Poop begins looking much less mucousy* He’s teething so a bit grumpy but otherwise he’s good.
Aug 17: (about 4 weeks on Neocate) *Poop is at baseline!*
By the end of August, Neocate was officially a pass! Transition and trial period took approximately two months.
Beena T. writes: I actually did a happy dance when we made it to the baseline poop album. It’s like winning an award in the baby reflux world! Success post to come soon!
Stacey M. asked: Beena, We are day 5 of full Neocate and this is definitely one of the worst nights we’ve had in a long time. Reflux is awful even though I’m holding him up all night. He’s been gassy (toots and burps). When your LO was gassy during the transition did you use any kind of gas drops? Any suggestions to help with the discomfort?
Beena T. replied: Stacey, Yes! We needed them three times a day during the transition. He was very gassy which made him uncomfortable. We stopped using them about a month into full formula because his body adjusted and the gas went wayyy down.
Look how long it took but how worth it the transition was in the end!! Baby reached a personal baseline for Neocate and is doing awesome!
Oct 3: We are struggling. Day 10 of Neocate transition so at 3oz Neocate in a 6 or 7oz bottle. He’s not eating his usual amount, crying like he’s hungry but then only taking a couple ounces and then spitting it out and gagging. He’s also gassy: lots of toots and BIG burps. We’ve got lots of things going on right now confounding my ability to troubleshoot. He had his 4 month vaccines on Wednesday. Thursday he slept a ton and didn’t want to eat much. Friday less sleep and less food. Today really fighting the bottles. He’s been such a happy content baby for many weeks now and today he had two bouts of hysterical crying. He took a couple ounces each time and then was happier but refused to eat more. He also is in a development leap right now and he learned to roll to tummy a week ago so has been sleeping that way most of the time. He has been sleeping through the night (8pm-7/7:30am) for 3 weeks. The last couple nights he’s woken a bit early in the morning, I suspect from hunger. He has been finishing his morning bottle without too much fuss.
The last thing going on is he’s been starting to move toward a 3.5-4 hour schedule because (before the shots) he had been extending wake time and not wanting to eat much at the three hour mark.
I don’t know if he really doesn’t like the formula or if he’s just not hungry (because of any of the reasons above). Or is it the gas? He doesn’t seem uncomfortable when passing it, per se.
Also, I’ve been preparing all of the Neocate for the next day at night in a formula pitcher. Baby has always drank bottles cold right from the fridge. Could either of these things impact the flavor? Does it get worse over time when it’s pre-mixed so that each bottle would taste worse throughout the day? Trying to figure out why the morning bottle isn’t an issue but it gets worse as the day goes on.
Sorry for the long comment. Just feeling overwhelmed and discouraged tonight.
Oct 4: My husband suggested the same as he was trying to talk me off the ledge: Let’s go back down to 2.5oz and stick with that for a week or so.
Oct 12: Yes, he’s doing much better! It really did take about 1.5 weeks after his vaccinations to get to a good place again where he wasn’t refusing bottles. I stopped using boiling water to prepare the night before. Now I use room temp filtered water and mix the day’s worth in the morning right before first bottle. Store in the fridge and he is still taking bottles cold like before. We are on second day of over 50% Neocate per bottle (4oz Neo/3oz Ali rtf). Spitting up is maybe a little elevated but I expected that due to the thinness of the Neocate. He’s napping well and still sleeping 11.5 hours at night. He’s currently happily bouncing and babbling in his jumper.
Oct 15: Poop check! We are on our 5th week of our transition to Neocate. We would expect to be on full Neocate a week and a half from now (so 6 full weeks for the transition period). Poop has been thinner lately (it’s soaking in to the diaper) and just wanted to check if this is expected.
Oct 26: poop pic. This is the worst poop I’ve seen since we switched from breast milk to Ali rtf 15 weeks ago. We are almost on full Neocate; three more days until done with transition. Could these dark spots be blood? I know “it gets worse before it gets better,” but what should I be looking for to indicate it’s an early fail? He’s been pooping more often and it’s getting increasingly liquidy. He’s eating, sleeping and generally happy. He will spit up immediately after feeds but has been tending to spit up when he wakes from nap, approximately four hours after the last feed. That spit up smells acidic. Sometimes it seems to make him uncomfortable…Oh and it seems like he’s extra gassy. He was fussing a lot during eating and trying to burp so I started giving him gas drops before every feed and that has helped. We takes the Mylicon and I’ve been adding the same one to his HC since the beginning so it’s not a new thing in his diet, but he’s getting more now
Nov 16: Poop update. 2.5 weeks on full Neocate…it was super dark green today. I’m mainly just concerned about the consistency. Super loose; soaking into the diaper. And I still see mucus
Nov 29: Poop check! 4 weeks on Neocate. It’s usually still pretty thin and dark green, soaking in to the diaper, but this one from Friday was different so thought it worth a pic. Seems really mucusy…Nothing new going in. It wasn’t even a new batch of HC. The only thing is that he may be teething. Periodically super upset and chewing everything. But I don’t feel anything coming through yet
Dec 4: poop check! 5 weeks on Neocate. Tylenol given when I said and none since. I did notice him spitting up more the day after the Tylenol. We won’t be giving it anymore…he’s good! Aside from that day of increased spitting up he’s been great. His spitting has noticeably decreased in recent weeks. He burps without stuff coming up and the delayed spitting is almost non-existent. I say all of this but he got his 6 month shots today (including flu shot) so….
Dec 11: 6 weeks on Neocate. 1 week post 6-month vaccinations, just in case we should track that …His symptoms seem very well controlled. He’s happy, gaining and growing perfectly, eats great (~28-30oz), sleeps like a champ, spit up is significantly reduced. I never suspect he’s in pain…He poops on average every day or so. Sometimes it’s daily, sometimes twice a day, sometimes he skips a day.
My gut (pun intended) is telling me that he’s in a good place and we should give solids a try soon. We will try the water starting tomorrow. Worth a shot.
[Baby’s poop isn’t quite what we would consider “baseline,” BUT Mom is making one more tweak with the type of water being used & then is going to start solids. Poop is close *enough* (PLEASE discuss this with us first!), & more importantly baby is in a GREAT place symptom-wise. There is no indication for changing to another formula.]
This mama’s Gerdling struggled tremendously getting onto Neocate, but baby is doing much better now that she’s adjusted to the elemental formula! Baby is doing great, and poop reached an eventual baseline. It took about three full weeks from starting the transition (the slow, increasing by 0.5 oz every 3 days transition that WE recommend) until baby was settled again.
Sept 17: she seems wayyyy more uncomfortable now with this new formula add. Like crying, screeching, tensing up. Even only with the 1/2 ounce would this happen…? Yesterday once we started the Neocate, she seems way more uncomfortable. Tensing up whole body, screeching, crying out, coughing, aggressively eating hand, very spazzy (if that makes sense). We are already giving her 20% over Marci dose recommendation to try and make her comfortable.
Sept 20: Ya we had a rough night, she was up every two hours, and at midnight I had to give some MCS.
Sept 23: On day 7 of Neocate transition… she has been waking up every 1-2 hours at night wanting to eat… normal? She doesn’t eat all that much during the day despite my efforts.. but then at night is famished…We just started adding 1.5 oz of Neocate today. So we are on day 7 of transition…
Sept 26: Baby woke up at midnight screaming in pain. Gave Pepcid, MCS… nothing was helping. She was choking on bottle again- she hasn’t done that in a while. Arching back, kicking legs… Day 10 of transition to Neocate.
Sept 30: I may not survive this formula change. She was up every 30 mins last night screaming and will not sleep today. Today is the first day of full Neocate and I will see this through, however, is there anything I can do to make her feel better. Already doing Pepcid in between meds and MCS.
Oct 1: [When an admin suggested that if things are absolutely unbearable, she could go back to Ali Rtf & try again later, mom decided to hunker down & get through it! ] I really don’t want to back track at this point. We had a better night, and a better-ish day today. I’m just really hoping in a few weeks this will have been a good decision. It doesn’t seem to be her reflux that’s bothering her- so that’s a plus… more tummy issues like gas, and burping.
Oct 6: two nights ago she only woke up one time (whoo hoo!!!) and didn’t seem too uncomfortable- I also haven’t had to give Pepcid lately! But then last night she was up every 2 hours again! Ugh. She doesn’t seem to be too uncomfortable when she wakes up, but why still waking so much?!
Oct 8: Omg! She slept ALL night last night! I am in shock and I want to cry I am so happy! I’m really hoping that’s a good sign this formula is working she has NEVER slept more than 4 hours straight in almost 6 months!
Oct 11: I kept going in her room and putting my finger under her nose!!! She has been sleeping pretty darn good the past 4 nights… so much better! She’s sleeping through the night or just one wake up- but not uncomfortable really. Still gas reflux but doesn’t seem to be painful at all.
Ashley also kept her own “journal” timeline of her baby’s symptoms so that she could share with other parents! Check it out below:
Transition to Neocate
Here is my success story with transition to Neocate. We are still waiting for a baseline poop but shots, sickness and teething have also been in the mix- hoping for baseline soon.
I wanted to write this post for anyone thinking of switching to Neocate. I documented our journey so I could reflect on how far we came, and to help any other families going through this same experience. It was a BRUTAL few weeks, but soooo worth it in the end. We did the slow transition, 0.5 oz increase every 3 days….
day 1-2 seemed okay, tad more gas.
day 3- way more uncomfortable, up at midnight very fussy, gave MCS
day 4- coughing and sneezing a lot, gagging, no sleep, kicking legs, arching
day 6- up every two hours in the night, kicking legs, gagging, coughing
day 8- uncomfortable, no sleep, very gassy
day 12- very uncomfortable, tenses up whole body, had to start giving Pepcid as well
day 14- feeling like I wouldn’t survive this transition. Seems like she’s in pain, very uncomfortable, no sleep, giving all the meds I can
day 15- full Neocate now. wont nap, crying, but slept a little better at night
day 16-19- very bad gas, needs to burp a lot, spitting up a lot more
day 20- awful again, having to force to drink oz’s, scratching at head a lot- maybe skin is healing (had cradle cap and eczema)
day 23- not the best naps, but seems to feel a bit better, and slept for 10 hours!!!!
day 24- minimal discomfort and minimal spit up!!!
day 26- still has SOME reflux but passes quickly, sleeping great!!! was able to finally sleep train and our lives were FOREVER changed!!
So as you can see it took a solid 4 weeks from time that we started the transition and a solid two weeks of being solely on Neocate to see a difference! I hope this helps any family that is out there who is struggling with the transition!
Warning: Poop Picture Below
These are a few examples of a typical elemental transition poop, in this case Neocate. There is bright yellow, almost orange, mucus in the stool. This baby went on to eventually reach baseline on Neocate after about 6 weeks fully on the formula.