Use Of Infant Formula Research Articles

The Cochrane Library and dietary prevention of allergic disease and food hypersensitivity in children: an umbrella review

AbstractBackgroundDietary interventions, including avoiding allergy‐inducing foods in pregnant or lactating women and their infants, and the use dietary modifications such as prebiotics and probiotics, may prevent sensitization and subsequent allergic disease and food hypersensitivity in infants.ObjectivesTo determine the evidence from Cochrane Systematic Reviews for dietary interventions for the primary prevention of clinical allergic disease or food hypersensitivity.MethodsThe Cochrane Database of Systematic Reviews was searched for systematic reviews examining prevention of allergic disease and/or food hypersensitivity. Two reviewers independently assessed review quality, reviewed assessments of study quality and extracted reported data.Main resultsSix reviews were eligible. All reviews had concerns regarding the methodological quality of included studies and several had insufficient numbers of enrolled infants to provide precise estimates of effect. There is insufficient evidence to support the use and safety of maternal dietary allergen restriction during pregnancy and/or lactation for prevention of allergic disease in high‐risk infants. In high‐risk infants unable to be exclusively breast‐fed, there is some evidence for use of a hydrolysed infant formula for prevention of allergic disease, although the evidence is not conclusive. Evidence suggests that soy‐based infant formula should not be recommended. One trial of prebiotic supplemented formula reported a significant reduction in eczema up to 6 months of age. Meta‐analysis of 5 trials of probiotic supplements found a significant reduction in infant eczema, although trial results were heterogeneous.Authors' conclusionsIn high‐risk infants, there is no evidence to support the use of dietary interventions in pregnant or lactating women, or the use of soy‐based formula in infants for prevention of allergic disease. There is insufficient evidence to recommend the use of prebiotics or probiotics. Further trials of hydrolysed infant formula, prebiotics and probiotics are warranted. Copyright © 2007 John Wiley & Sons, Ltd.

Custo da alimentação no primeiro ano de vida

OBJETIVO: Estimar e comparar os custos das diferentes alternativas de alimentação disponíveis para lactentes no primeiro ano de vida, considerando as limitações de cada opção em relação ao oferecimento de uma alimentação adequada ao crescimento e desenvolvimento e ao orçamento da família. MÉTODOS: Foram calculadas quatro alternativas de alimentação no primeiro ano de vida, segundo a recomendação atual da introdução dos novos alimentos. Os custos foram propostos para o consumo mensal de tal alimentação. Os valores obtidos foram determinados pela coleta de preços dos gêneros alimentícios praticados em duas redes de supermercado e um mercado local da zona sul de São Paulo, utilizando os gêneros de menor preço e determinando a média aritmética desses três locais no período de seis meses (janeiro a junho de 2004). RESULTADOS: Observou-se que a partir do cálculo do custo percentual em relação ao aleitamento materno mais alimentação complementar, o uso de fórmula infantil representa custo 3,3 vezes maior, e o uso do leite de vaca 1,7 vezes maior do que o valor do custo do aleitamento materno, demonstrando, assim, que a recomendação de utilização da fórmula infantil não pode ser adotada pela maior parte da população brasileira, devido às suas limitações de renda. CONCLUSÃO: O desenvolvimento de formulado, no molde dos medicamentos genéricos, poderia oferecer opção alimentar com os nutrientes necessários para o crescimento e desenvolvimento infantil. Este produto, com custo em torno de R$10,00/kg, apresentaria preço menor que a metade dos valores praticados atualmente para os formulados disponíveis no mercado.

Progress in Promoting Breast-Feeding, Combating Malnutrition, and Composition and Use of Infant Formula, 1981–2006

More than 90% of women in developing countries and 50 to 90% of women in industrialized countries now initiate breast-feeding, a marked improvement from 25 y ago. The duration of breast-feeding has lengthened, but fewer than 35% of infants worldwide are still exclusively breast-fed at 4 mo of age. Considerable progress has also been made in combating infant malnutrition. In 1980, 47% of under-5-y-old children in developing countries were stunted. This percentage declined to 29% in 2005. Major advances in formula use and composition include the introduction of formulas tailored to the perceived needs of low-birth-weight infants and the development of fortifiers to overcome the nutritional deficits of human milk for the preterm infant. More recently, postdischarge formulas were introduced and are now being used widely, often in combination with breast-feeding. Formulas for term infants also have undergone a number of changes in the past 25 y to better reproduce the composition of human milk and/or the response of the breast-fed infant. The use of whey-predominant rather than casein-predominant formulas has increased, as has the use of iron-fortified formulas. Cow’s milk is introduced into the infant’s diet much later than 25 y ago. Despite the progress that has been made in promoting breast-feeding and in the quality of infant formulas, further improvements in the duration of breast-feeding and in the composition of infant formulas are needed.

Prevalence of Overweight and Obesity in Nigerian Preschool Children

The problem of obesity is taking a worldwide dimension. However, there is paucity of data on obesity in Nigerian children. This study was therefore conducted to determine the prevalence and factors associated with overweight and obesity among Nigerian preschool children. A total of 270 children were recruited from 216 households using multistage cluster sampling technique. The prevalence of overweight and obesity were 13.7% and 5.2% respectively while the prevalence of underweight was 8.5%. Although, there was no statistically significant relationship between exclusive breastfeeding for 6 months, duration of breastfeeding and the prevalence of overweight (P = 0.569, 0.669 respectively), the prevalence of overweight decreases with increase in the duration of breastfeeding. Ninety-nine (36.3%) children were given infant formula feeds with 92 (93.9%) children introduced to infant formula feeds before the age of 6 months. The use of infant formula feeds was significantly associated with reduction in the prevalence of overweight (P = 0.041). No linear relationship was detected in the association between overweight and socioeconomic class. The population shows heterogeneity in their nutritional problem by having mixture of obesity and underweight. There is need for trend of obesity to be monitored so that timely intervention will be taken and associated morbidity and mortality from obesity prevented.

A PILOT SURVEY TO IDENTIFY RISK FACTORS IN PEDIATRIC PATIENTS WITH EOSINOPHILIC ESOPHAGITIS

Pediatric eosinophilic esophagitis (EoE) has evolved over the past 30 years from isolated case reports of patients with prominent esophageal eosinophilia to a recognized clinical disorder frequently misdiagnosed as refractory GERD. Eosinophilic esophagitis can be defined as the presence of 20 or more eosinophils per high-powered field in esophageal mucosal endoscopic biopsies that does not respond to acid blockade. At present there is no literature characterizing the demographic, environmental, infant, maternal or genetic risk factors associated with pediatric eosinophilic esophagitis. Our aim was to design a comprehensive multi-modality (internet, phone, mail and personal interview) questionnaire to help determine the risk factors associated with children who develop eosinophilic esophagitis. Our questionnaire entails over 75 questions focused on areas of patient demographics and environmental exposures in addition to family and patient allergic and infection data. From our eosinophilic esophagitis database of over 400 patients, we conducted a pilot study. Of the 15 families surveyed, 80% were Caucasian and 71% of families earned over $75,000/year. Only one patient was exclusively breast fed, and infant formula was used alone or in combination with breast milk in 93% of children. Twelve of the fifteen families (80%) used antibiotic hand soaps and did not have their children attend daycare. Additionally, 93% of families had a personal or family atopic history (asthma, eczema, environmental or food allergies). Skin and patch testing demonstrated food allergens in 87% and environmental allergens in 53% of patients. There were no differences in the number of patient infections or antibiotic use. In conclusion, EoE correlates with family atopic history, infant formula use, upper middle class income and the use of antibiotic hand soap. Larger in depth studies need to be performed.

Breastfeeding, infant formula supplementation, and Autistic Disorder: the results of a parent survey

BackgroundAlthough Autistic Disorder is associated with several congenital conditions, the cause for most cases is unknown. The present study was undertaken to determine whether breastfeeding or the use of infant formula supplemented with docosahexaenoic acid and arachidonic acid is associated with Autistic Disorder. The hypothesis is that breastfeeding and use of infant formula supplemented with docosahexaenoic acid/arachidonic acid are protective for Autistic Disorder.MethodsThis is a case-control study using data from the Autism Internet Research Survey, an online parental survey conducted from February to April 2005 with results for 861 children with Autistic Disorder and 123 control children. The analyses were performed using logistic regression.ResultsAbsence of breastfeeding when compared to breastfeeding for more than six months was significantly associated with an increase in the odds of having autistic disorder when all cases were considered (OR 2.48, 95% CI 1.42, 4.35) and after limiting cases to children with regression in development (OR 1.95, 95% CI 1.01, 3.78). Use of infant formula without docosahexaenoic acid and arachidonic acid supplementation versus exclusive breastfeeding was associated with a significant increase in the odds of autistic disorder when all cases were considered (OR 4.41, 95% CI 1.24, 15.7) and after limiting cases to children with regression in development (OR 12.96, 95% CI 1.27, 132).ConclusionThe results of this preliminary study indicate that children who were not breastfed or were fed infant formula without docosahexaenoic acid/arachidonic acid supplementation were significantly more likely to have autistic disorder.

WIC's promotion of infant formula in the United States

BackgroundThe United States' Special Supplemental Nutrition Program for Women, Infants and Children (WIC) distributes about half the infant formula used in the United States at no cost to the families. This is a matter of concern because it is known that feeding with infant formula results in worse health outcomes for infants than breastfeeding.DiscussionThe evidence that is available indicates that the WIC program has the effect of promoting the use of infant formula, thus placing infants at higher risk. Moreover, the program violates the widely accepted principles that have been set out in the International Code of Marketing of Breast-milk Substitutes and in the human right to adequate food.SummaryThere is no good reason for an agency of government to distribute large quantities of free infant formula. It is recommended that the large-scale distribution of free infant formula by the WIC program should be phased out.

Barriers to accessing PMTCT services in a rural area of South Africa

Despite good intentions and commitment from providers, prevention-of-mother-to-child-transmission of HIV (PMTCT) services can be difficult for pregnant women to access, despite the provision of free health services for women and children. We examined the introduction of PMTCT services in a very poor rural area of the Eastern Cape, South Africa, to assess the context's impact on the provision of this service. Our approach involved 13 individual in-depth interviews and 26 focus group discussions, spread over six clinics in a single district, supplemented by situational observations. Our goal was to suggest how access to PMTCT services at the clinics may be improved. Poor roads, an underdeveloped transport system and poor telecommunications typify the pervasive poverty in the study area. Families have few resources for travel and most live a long distance from a clinic. Accessing emergency transport is especially difficult and expensive. Poor infrastructure also means that many families do not have access to clean water, which complicates the use of infant formula. PMTCT services had been recently added to several clinics that provide general services to the local population, but that were already understaffed and over-pressured. Since the PMTCT services were new, some elements of the intervention and staff training were delayed, thus inhibiting full implementation. New staff had not been added to ease accumulated pressures. Thus, socio-economic context can present a formidable barrier to the provision of PMTCT services. Improvement in services to rural areas will require creative thinking, perhaps including the use of mobile services and the development of community structures, such as contributions to community health education by traditional birth attendants and local volunteer groups.

Subchronic (13-week) oral toxicity study, preceded by an in utero exposure phase, with arachidonate-enriched triglyceride oil (SUNTGA40S) in rats

Polyunsaturated fatty acids (PUFAs), such as arachidonic acid (ARA) and docosahexaenoic acid (DHA) are natural constituents found in human milk, fish oil or egg yolk. Until recently, infant formulas, though providing the essential fatty acid precursors for these PUFAs, did not contain preformed ARA or DHA. In this study the safety of SUNTGA40S as source of ARA, not only for use in infant formulas but also for nutritional products or food supplements, was evaluated in a subchronic study in Wistar rats, preceded by a 4-week pretreatment period of parental (F 0) rats and exposure of the F 0 dams throughout mating, gestation and lactation. SUNTGA40S was administered at dietary levels of 0.5%, 1.5% and 5% (wt/wt) adjusted with corn oil to 5.76% added fat. An additional group received 3.65% (wt/wt) SUNTGA40S in conjunction with 2.11% (wt/wt) high DHA Tuna oil, providing an ARA:DHA ratio of 2.7:1. High-fat and low-fat controls received basal diet with or without 5.76% corn-oil supplement. The content, stability and homogeneous distribution of the test substances in the diet were confirmed under study conditions. The administration of SUNTGA40S, with or without DHA oil, did not affect health, growth, fertility or reproductive performance of the parental rats, nor pup characteristics (condition, weight gain, viability, number per litter or sex ratio). In the subchronic study with the offspring (F 1) rats, no significant differences were found in condition, neurobehavioural observations, ophthalmoscopy, growth, urinalysis or macroscopic and microscopic findings between the test groups and the low-fat or the high-fat controls. In males of the 5% SUNTGA40S and the SUNTGA40S/DHA group, red blood cell counts, haemoglobin concentration and packed cell volume were lower and reticulocytes were slightly higher than in the high-fat and low-fat control groups. Cholesterol, triglycerides and phospholipids in plasma were lower than in the high-fat controls in both sexes in the 5% SUNTGA40S and the SUNTGA40S/DHA group and (for triglycerides only) in the 1.5% SUNTGA group. Due to the administration of extra dietary fat, food intake and prothrombin time (males only) were lower and alkaline phosphatase activity was higher in all the high-fat groups, including the corn-oil controls, as compared to the low-fat controls. The weight of the spleen was higher in males of the 5% SUNTGA40S and the SUNTGA40S/DHA group compared to both the low-fat and the high-fat controls. The effects noted in this study at high dose levels of SUNTGA40S are consistent with previously reported physiological responses to dietary intake of high PUFA containing oils. The present results provide evidence that SUNTGA40S is a safe source of arachidonic acid. Except during lactation when the intake in dams doubled, 5% Suntga40S in the diet was equivalent to an overall intake of approximately 3 g/kg body weight/day in F 0 and F 1 animals.

Infant Feeding Practices Before Implementing Alternatives to Prolonged Breastfeeding to Reduce HIV Transmission Through Breastmilk in Abidjan, Côte d'Ivoire

The aim of this study was to describe baseline infant feeding practices in women of unknown HIV status in Abidjan, Côte d'Ivoire, before the implementation of infant feeding interventions aimed at the prevention of mother-to-child transmission of HIV through breastmilk. We conducted a cross-sectional survey in March 2000 among 225 mothers attending community-run health facilities with their own child for either immunization or weighting. All but two children had ever been breastfed, of whom 94 per cent were still being breastfed at 6 months of age. Exclusive breastfeeding was not practiced in this population since all women had given water to their child, starting in median one day after birth. Moreover, 20 per cent of the mothers had introduced infant formula in median three weeks after delivery. This study provides useful information for planning purposes in this urban African population, where exclusive breastfeeding is rare and the use of infant formula relatively common.

Lipase-Catalyzed Acidolysis of Tripalmitin with Hazelnut Oil Fatty Acids and Stearic Acid To Produce Human Milk Fat Substitutes

Structured lipids (SLs) containing palmitic, oleic, stearic, and linoleic acids, resembling human milk fat (HMF), were synthesized by enzymatic acidolysis reactions between tripalmitin, hazelnut oil fatty acids, and stearic acid. Commercially immobilized sn-1,3-specific lipase, Lipozyme RM IM, obtained from Rhizomucor miehei was used as the biocatalyst for the enzymatic acidolysis reactions. The effects of substrate molar ratio, reaction temperature, and reaction time on the incorporation of stearic and oleic acids were investigated. The acidolysis reactions were performed by incubating 1:1.5:0.5, 1:3:0.75, 1:6:1, 1:9:1.25, and 1:12:1.5 substrate molar ratios of tripalmitin/hazelnut oil fatty acids/stearic acid in 3 mL of n-hexane at 55, 60, and 65 degrees C using 10% (total weight of substrates) of Lipozyme RM IM for 3, 6, 12, and 24 h. The fatty acid composition of reaction products was analyzed by gas-liquid chromatography (GLC). The fatty acids at the sn-2 position were identified after pancreatic lipase hydrolysis and GLC analysis. The results showed that the highest C18:1 incorporation (47.1%) and highest C18:1/C16:0 ratio were obtained at 65 degrees C and 24 h of incubation with the highest substrate molar ratio of 1:12:1.5. The highest incorporation of stearic acid was achieved at a 1:3:0.75 substrate molar ratio at 60 degrees C and 24 h. For both oleic and stearic acids, the incorporation level increased with reaction time. The SLs produced in this study have potential use in infant formulas.

Genetic and environmental risk factors for the development of food allergy

To review recent clinical and experimental studies of genetic and environmental risk factors for the development of food allergy. It may be true, although it is yet to be shown, that food allergies in early childhood are becoming more common and that the causes are the same as for later-developing respiratory allergies. The mother not only transfers 50% of her genes to her baby, but she is also the exclusive environment during gestation and continues to be a major environmental factor while breast-feeding her infant. Non-genetic maternal influences increasing the likelihood of food allergy include Caesarian section and high maternal age. Allergy to sesame seems to be increasing in children. This is possibly a consequence of increased use in processed foods. The search for dietary risk factors is not limited to allergenic foods, but may include other nutrients, for example excessive intake of vitamins. Two meta-analyses have seriously questioned the use of special infant formulas for allergy prevention. Novel prevention strategies, such as probiotic bacteria, have yet to be documented further. The causes of food allergy are still unknown and no particular genes associated particularly with food allergy have been identified, although there is a strong association in general between genetic susceptibility to food allergy and that to IgE-mediated allergy. There are still no measures for general recommendation in order to prevent food allergy and no genes have been linked conclusively to disease. Further research concentrating on food allergy is obviously needed.

New Investigator Award, Blue Ribbon Abstract Award: Fatal Enterobacter sakazakii infection associated with powdered infant formula in a neonatal intensive care unit in New Zealand

BACKGROUND: Enterobacter sakazakii (E. sakazakii), a gram-negative bacillus of the Enterobacteriacae family, is a rare cause of meningitis, bacteremia, and necrotizing enterocolitis in infants. The population at particular risk is infants born prematurely, of low birthweight, or with compromised immunity. In 2004, an outbreak investigation was initiated in our neonatal intensive care unit (NICU) when a 5-day-old premature baby was found to be growing E. sakazakii in blood culture. The index case (Baby A) was born at 33 weeks gestation and admitted to NICU for observation. She received few medications and was fed with a combination of expressed breastmilk and infant formula. Five days after birth, Baby A became unwell. Despite treatment, she suffered progressive neurological damage and died on day 18. METHODS: The organism identification was confirmed and background microbiology isolate rates ascertained: 0-2 isolates per year were found, but no isolate had originated from NICU. A review of international literature revealed an association between E. sakazakii infection in neonates and the use of powdered infant formula. The cohort of neonates present in NICU had feces samples collected for culture along with demographic and risk factor/exposure data. A case patient was any neonate diagnosed with E. sakazakii infection (confirmed or suspected) or colonization who had been in NICU during the 5-day study period. Samples of medications, water, powdered infant formula, and breastmilk and samples from surfaces and equipment in formula preparation areas were among environmental specimens cultured. All aspects of infant formula preparation and use were reviewed, along with patient care practices within NICU. Use of sterile ready-to feed formula was implemented. RESULTS: Of 24 babies screened, four babies were identified as being colonized with E. sakazakii. None became clinically unwell. Two types of powdered infant formula were positive for E. sakazakii. Pulsed-field gel electrophoresis (PFGE) analysis found that E. sakazakii isolated from the index case, all four colonized cases, and one batch of powdered infant formula were all indistinguishable. The index case and two colonized babies had received this type of formula. CONCLUSIONS: Powdered infant formula is not a sterile product and may be contaminated with E. sakazakii. International recommendations advocating the use of sterile liquid formula for NICU babies should be widely publicized.

A NEW MIXTURE OF NEUTRAL AND ACIDIC OLIGOSACCHARIDES AND THEIR IMMUNE-MODULATORY CAPABILITIES

ST07 NUTRITIONAL COMPONENTS WITH FUNCTIONAL EFFECTS ON HOST DEFENCE DURING INFANCY Satellite Symposium organized by NUTRICIA BABY FOOD Introduction: Breast feeding is associated with a lower incidence of allergic and infectious diseases. This effect is due in part to the stimulatory effect of the intestinal flora on the postnatal development of the immune system. Along with other components of human milk, oligosaccharides play a key role in positively influencing the postnatal development of the intestinal flora. Human milk oligosaccharides contain app. 80% neutral and 20% acidic structures. In the search for functional analogues of human milk oligosaccharides for use in infant formulas, we developed a mixture of neutral oligosaccharides consisting of galacto-oligosaccharides (GOS) and long chain fructooligosaccharides (FOS). More recently, we have also investigated acidic oligosaccharides (AOS) derived from pectin hydrolysate. Results: In several clinical trials we have demonstrated that feeding a formula supplemented with this mixture of neutral oligosaccharides results in an entire intestinal flora similar to that found in breast fed infants. As with the oligosaccharides from human milk, GOS, FOS and AOS are resistant to digestion in the gastrointestinal tract and they can be detected in the faeces. The short chain fatty acid pattern in the stools of infants fed a GOS/FOS supplemented formula is characterized by a high percentage of acetate and a low percentage of butyrate and propionate, thus mimicking the short chain fatty acid pattern in the stools of breast fed infants. This high level of acetate may help to strengthen the gut barrier since acetate is more effective than either propionate or butyrate in stimulating an increased PGE1/PGE2 ratio, which has a mucroprotective effect (mucin quantity and mucin quality). In a study using the mouse vaccination model, feeding GOS/FOS stimulated a more balanced Th1/Th2 immune response. Also, in an animal model for allergic hypersensitivity using ovalbumin as the allergen, dietary GOS/FOS inhibited allergic inflammation. In both models, the addition of AOS to the GOS/FOS mixture increased significantly the immune modulatory outcome, indicating a synergistic effect of GOS/FOS and AOS. Both the mixture of GOS/FOS alone (0.8 g/dl) or in combination with AOS (0.6 g GOS/FOS plus 0.2 g AOS/dl) are well tolerated by infants. Conclusion: The data from our studies demonstrate that dietary oligosaccharides, as a mixture of GOS/FOS alone or in combination with AOS, can positively influence the entire intestinal flora and the postnatal development of the immune system. Further research will demonstrate whether these substances can play an important role in allergy prevention.

The association of progesterone, infant formula use and pacifier use with the return of menstruation in breastfeeding women: a prospective cohort study

Objectives: This study sought to explore hormonal and postnatal factors, which are associated with the return of menstruation in breastfeeding mothers. Design: A prospective cohort study in Bristol, UK. Ninety-one breastfeeding mothers of mixed parity were recruited at community-based antenatal clinics. Eighty-five mothers completed all stages and informed us about the return of menstruation. Data were collected from interviews and questionnaires antenatally, immediately postnatally, and 1 week, 4 weeks and 6 months later. Blood samples were taken at all time points except at 6 months. Associations between hormone levels, postnatal factors and the return of menstruation were explored using univariate and multivariate statistical survival analysis. Results: Sixty-five (76%) mothers were still breastfeeding at 6 months and 46 (54%) of these were fully breastfeeding (not giving formula milk); 21 (32%) mothers started menstruating in the first 6 months whilst they were still breastfeeding and 14 were fully breastfeeding at 6 months. Survival analysis modelling showed that formula use (RR=4.27; 95% CI=1.89, 9.67), pacifier (dummy) use (RR=3.26; 95% CI=1.35, 7.84) and lower postnatal progesterone levels (P=0.006) each made a significant contribution to the chance of earlier resumption of menstruation. Prolactin and oestradiol levels showed no associations with the return of menstruation. Conclusions: Higher postnatal progesterone levels are associated with delayed menstruation; while the use of pacifiers and infant formula milk are associated with an earlier return to menstruation.

The association of progesterone, infant formula use and pacifier use with the return of menstruation in breastfeeding women: a prospective cohort study

Objectives: This study sought to explore hormonal and postnatal factors, which are associated with the return of menstruation in breastfeeding mothers. Design: A prospective cohort study in Bristol, UK. Ninety-one breastfeeding mothers of mixed parity were recruited at community-based antenatal clinics. Eighty-five mothers completed all stages and informed us about the return of menstruation. Data were collected from interviews and questionnaires antenatally, immediately postnatally, and 1 week, 4 weeks and 6 months later. Blood samples were taken at all time points except at 6 months. Associations between hormone levels, postnatal factors and the return of menstruation were explored using univariate and multivariate statistical survival analysis. Results: Sixty-five (76%) mothers were still breastfeeding at 6 months and 46 (54%) of these were fully breastfeeding (not giving formula milk); 21 (32%) mothers started menstruating in the first 6 months whilst they were still breastfeeding and 14 were fully breastfeeding at 6 months. Survival analysis modelling showed that formula use (RR=4.27; 95% CI=1.89, 9.67), pacifier (dummy) use (RR=3.26; 95% CI=1.35, 7.84) and lower postnatal progesterone levels ( P=0.006) each made a significant contribution to the chance of earlier resumption of menstruation. Prolactin and oestradiol levels showed no associations with the return of menstruation. Conclusions: Higher postnatal progesterone levels are associated with delayed menstruation; while the use of pacifiers and infant formula milk are associated with an earlier return to menstruation.

In vitro digestion of novel milk protein ingredients for use in infant formulas: Research on biological functions

Rather than using lengthy clinical studies, in vitro digestion of milk proteins by human neonatal gastric juice at pH values representing those in early neonatal life was investigated. Human milk proteins resisting digestion were immunoglobulins, secretory IgA, α S1-casein, secretory component, osteopontin and MUC-1. Bovine milk proteins resisting digestion at pH 4.0 were immunoglobulins, BSA, caseins, lactadherin, osteopontin, EPV20 and proteose peptone component 3 (PP3). Some proteins were rapidly digested e.g. CGMP. In vitro digestion provides rapid information regarding the susceptibility of proteins to gastric proteases and is a convenient alternative to clinical studies.

Use of whole cow's milk in late infancy – Change tack or stay the course?

In this edition of Paediatics & Child Health, Drs Leung and Sauve provide a compelling argument to change the present Canadian Paediatric Society’s recommendations for the use of iron-fortified formula in nonbreastfed infants from nine to 12 months of age to the American recommendation of 12 months (1,2). At first glance this seems to be a ‘no brainer’. Iron deficiency anemia is an important nutritional deficiency in both Canadian and American children (3–8). Iron deficiency associated with the use of whole cow’s milk in infants derives from a combination of poor dietary availability and the presence of occult blood loss in infants under six months of age (3,4). Early iron deficiency may result in lower developmental and behavioural scores in children later in early childhood (9,10). On closer scrutiny, the case for a change may be less secure. Iron deficiency is essentially a condition that reflects a poverty of body iron stores. This may result from the impoverished nutritional endowment associated with prematurity. Alternatively, iron deficiency directly reflects the economic poverty of families. Native infants and children from poor families account for the largest proportion of anemic children detected at one year of age (6). Infants from Canadian families of oriental background are also at risk (7). In most instances, anemia is due to the use of whole cow’s milk from early infancy in spite of the current recommendation that counsels against this practice. It is unlikely that a recommendation for extension in the use of infant formula to one year of age would in any way impact the early introduction of ‘store milk’ in the population at greatest risk of this problem. In many instances, parents use ‘store milk’ because they cannot afford to purchase more expensive formula. In other words, a recommendation to extend the use of formula is most likely to be adopted by a population of parents least likely to have affected children and least likely to be adopted in circumstances most likely to result in anemia. This phenomenon is not unique to iron deficiency anemia and is common to many problems in nutrition across a population. There are two rebuttals to this logic. The first is that, by adopting the recommendation for a longer period of formula feeding, Americans have lowered the prevalence of iron deficiency. The second is that, in the absence of any additional risk, extending the use of formula may help some children. However, it is most likely that the lower incidence of iron deficiency in the United States has resulted from the Special Supplemental Nutrition Program for Women, Infants and Children that provides nutritional supplements to pregnant women and their infants from lower socioeconomic groups (11). In other words, the more effective part of the policy was the targeting of poor families as the population at risk of iron deficiency owing to the early introduction of whole cow’s milk. Canadian health authorities have considered this approach but have shied away from providing free or subsidized formula to poor families because they fear being criticized for undermining breastfeeding. The second hypothesis is similarly skewed. A recommendation to extend the use of formula from the present nine to 12 months of age to 12 months of age would require families to purchase formula rather than milk for nonbreastfed infants. This would affect close to 350,000 families purchasing 1 L per day of formula at a premium of approximately $2 per day for an additional 90 days (12). Families with young children have many competing priorities for the $63,000,000 in increased expenditure. By purchasing store milk rather than formula, a family might benefit more by investing the $180 in additional vaccine coverage or a registered education savings plan for their child, especially if there is no evidence that the extra expense would provide additional health benefits. If whole cow’s milk is introduced at nine months of age with appropriate meats or iron-rich foods, the risk of iron deficiency is lessened. The risk is further decreased by limiting milk and juice intake to optimize the intake of these other foods. These phenomena are characteristic of many issues in population nutrition. It is tempting, but often ineffective, to use broad stroke national policy to deal with issues such as vitamin D deficiency or iron deficiency in a country as diverse as Canada. In these matters, we should ask, whether we would be better to invest limited funds in populations at risk, rather than adopting a recommendation that may be least likely followed in the sector where the problem exists. If we are going to change course, why not steer toward the cause of anemia and invest more in nurturing the mothers of infants vulnerable to this problem?

Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants.

Allergies and food reactions are common and may be associated with foods including adapted cow's milk formulas. Formulas containing hydrolysed proteins have been used to treat infants with allergy or food intolerance, and have been advocated for prevention of allergy and food intolerance in infants. To determine whether use of hydrolysed formulas for infant feeding prevents allergy and food intolerance. If hydrolysed formulas are effective, to determine what type of hydrolysed formula is most effective including extensively and partially hydrolysed formulas. To determine which infants benefit including infants at low or high risk of allergy and infants receiving early, short term or prolonged formula feeding. The standard search strategy of the Cochrane Neonatal Review Group was used including searches of the Cochrane Controlled Trials Register (2003, Issue 1), MEDLINE (1966 - January 2003), EMBASE (1980 - January 2003) and CINAHL (1982 - January 2003) and previous reviews including cross references. Randomised and quasi-randomised trials that compare the use of a hydrolysed infant formula to human milk or cow's milk formula. Trials with >80% follow up of participants were eligible for inclusion. Eligibility of studies for inclusion, methodological quality and data extraction were assessed independently by each reviewer. Primary outcomes included clinical allergy, specific allergies and food intolerance. Meta-analysis was conducted using a fixed effects model. Eighteen trials met criteria for inclusion. No eligible trials compared prolonged hydrolysed formula to human milk feeding. Two trials compared early, short term hydrolysed formula to human milk feeding and reported no significant difference in infant allergy or childhood cow's milk allergy (CMA). Two trials compared early, short term hydrolysed formula to cow's milk formula feeding with no significant benefits reported. One large quasi-random study reported a reduction in infant CMA of borderline significance in low risk infants (RR 0.62, 95% CI 0.38, 1.00).Seven studies compared prolonged feeding of hydrolysed formula to cow's milk formula without using co-interventions for allergy prevention. Meta-analysis of 4 studies (386 infants) found a significant reduction in allergy incidence in infancy (typical RR 0.63, 95% CI 0.47, 0.85; RD -0.15, 95% CI -0.25, -0.06). One study reported a significant reduction in allergy incidence in childhood (RR 0.54, 95% CI 0.36, 0.81). Significant reductions were found in asthma prevalence in childhood, eczema incidence in infancy and prevalence in childhood, food allergy prevalence in childhood, and CMA incidence in infancy. All studies enrolled infants at high risk of allergy. Only three trials comparing prolonged hydrolysed formula feeding to cow's milk formula feeding were considered of good methodology. Only one of these trials demonstrated a benefit into childhood (5 years of age). No eligible trials examined the effects of prolonged hydrolysed formula feeding on allergy beyond early childhood. Costs were not reported. Three trials compared prolonged feeding with an extensive to a partially hydrolysed formula and reported no significant difference in allergy incidence in infancy. There is no evidence to support feeding with a hydrolysed formula for the prevention of allergy in preference to exclusive breast feeding. In high risk infants who are unable to be completely breast fed, there is evidence that prolonged feeding with a hydrolysed compared to a cow's milk formula reduces infant and childhood allergy and infant CMA. Further trials are required to determine if significant clinical benefits persist beyond 5 years of age and if there is any additional benefit from use of an extensive compared to a partially hydrolysed formula. Incremental costs of formula and the effect on compliance should be measured.

Safety evaluation of sources of docosahexaenoic acid and arachidonic acid for use in infant formulas in newborn piglets

Human milk provides small quantities of preformed docosahexaenoic acid (DHA) and arachidonic acid (ARA), usually less than 1% of total fatty acids. Vegetable oil blends commonly used in infant formulas have, until recently, provided the essential fatty acid precursors for these long-chain polyunsaturated fatty acids (LCPUFA), but no preformed DHA and ARA. This study evaluated the safety of ingredient sources of DHA and ARA for use in infant formulas in a neonatal piglet model. Newborn piglets were allowed to suckle for 3 days and then divided into 4 feeding groups of 6 males and 6 females. Piglets were bottle-fed at frequent feeding intervals until 19 days of age. The composition of the piglet formulas was modeled after standard milk-based formulas for human infants while meeting nutritional requirements for piglets. Formulas were a control formula (no added DHA or ARA), a DHA formula providing 55 mg DHA/100 Cal, an ARA formula providing 96 mg/100 Cal ARA, and a DHA+ARA formula providing 34 mg DHA and 62 mg ARA/100 Cal. All formulas were equal in fat content and provided approximately 1000 Cal/l. The ARA-rich oil was from a fermentation product of Mortierella alpina (40 wt.% fatty acids as ARA) and DHA was from high DHA tuna oil (25 wt.% fatty acids as DHA). There were no test article related effects of DHA and/or ARA indicative of an adverse health consequence to the animals seen in the clinical signs, body weights, food consumption, clinical chemistry, hematology, organ weights or gross or histopathology. The findings in this neonatal animal study support the safety of these ingredient oil sources of DHA and ARA for use in infant formulas.