Breast-feeding: A commentary by the ESPGHAN Committee on Nutrition

lncRNA NORAD is consistently detected in breastmilk exosomes and its expression is downregulated in mothers of preterm infants

Breast milk is the ideal food for infants and undoubtedly has immediate and long-term benefits. Breast milk contains extracellular vesicles (EVs) i.e., exosomes secreted by maternal breast cells. Exosomes carry genetic material, such as long non-coding RNAs (lncRNAs), which possibly participate in cell-to-cell communications, as they are known to regulate critical gene pathways. The aim of the present study was to screen human breastmilk exosomes for their lncRNA cargo and to examine exosomal lncRNA levels associated with milk obtained from mothers that gave birth at term or prematurely (<37 weeks of gestation). Samples were collected at 3 weeks postpartum from 20 healthy, breastfeeding mothers; 10 mothers had given birth at full-term and 10 mothers preterm. Exosomal RNA was extracted from all samples and the expression of 88 distinct lncRNAs was determined using reverse transcription-quantitative PCR. A total of 13 lncRNAs were detected in ≥85% of the samples, while 31 were detected in ≥50% of the samples. Differential expression analysis of the lncRNAs between the two groups revealed ≥2-fold differences, with generally higher lncRNA concentrations found in the milk of the mothers that gave birth at term compared with those that gave birth preterm. Among these, the non-coding RNA activated at DNA damage (NORAD) was prominently detected in both groups, and its expression was significantly downregulated in the breast milk exosomes of mothers who delivered preterm. On the whole, the present study demonstrates that breast milk lncRNAs may be important factors of normal early human development. Collectively, the presence of lncRNAs in human breast milk may explain the consistent inability of researchers to fully 'humanize' animal milk.

Human milk microbiome: From actual knowledge to future perspective

Human milk is the gold standard for infant nutrition during the first months of life since it is perfectly adapted to the neonatal nutritional requirements and supports infant growth and development. Human milk contains a complex nutritional and bioactive composition including microorganisms and oligosaccharides which would also contribute to the gut and immune system maturation. Despite the growing evidence, the factors contributing to milk microbes' variations and the potential functions on the infant's gut are still uncovered. This short-review provides a general overview of milk microbiota, potential factors shaping its composition, contribution to the infant microbiota and immune system development, including the suggested biological relevance for infant health as well as the description of tools and strategies aimed to restore and module microbes in milk.

Human Milk, More Than Simple Nourishment

Human breast milk not only has nutritional properties but also holds a functional role. It contains various bioactive factors (lactoferrin, lysozyme, leukocytes, immunoglobulins, cytokines, hormones, human milk oligosaccharides, microbiome, microRNAs and stem cells) shown to contribute to several short- and long-term health outcomes. Some of these factors appear to be involved in the infant's neuro-cognitive development, anti-oncogenic processes, cellular communication and differentiation. Furthermore, breast milk is increasingly recognized to have dynamic characteristics and to play a fundamental role in the cross-talking mother-neonate. This narrative review aims to provide a summary and an update on these bioactive substances, exploring their functions mainly on immunomodulation, microbiome and virome development. Although the knowledge about breast milk potentiality has significantly improved, leading to discovering unexpected functions, the exact mechanisms with which breast milk exercises its bioactivity have not been completely clarified. This can represent a fertile ground for exploring and understanding the complexity behind these functional elements to develop new therapeutic strategies.

From Mum to Bum: An Observational Study Protocol to Follow Digestion of Human Milk Oligosaccharides and Glycoproteins from Mother to Preterm Infant

The nutritional requirements of preterm infants are challenging to meet in neonatal care, yet crucial for their growth, development and health. Aberrant maturation of the gastrointestinal tract and the microbiota could affect the digestion of human milk and its nutritional value considerably. Therefore, the main objective of the proposed research is to investigate how the intestinal microbiota of preterm and full-term infants differ in their ability to extract energy and nutrients from oligosaccharides and glycoproteins in human milk. This pilot study will be an observational, single-center study performed at the Neonatal Intensive Care Unit at Isala Women and Children's Hospital (Zwolle, The Netherlands). A cohort of thirty mother-infant pairs (preterm ≤30 weeks of gestation, n = 15; full-term 37-42 weeks of gestation, n = 15) will be followed during the first six postnatal weeks with follow-up at three- and six-months postnatal age. We will collect human milk of all mothers, gastric aspirates of preterm infants and fecal samples of all infants. A combination of 16S rRNA amplicon sequencing, proteomics, peptidomics, carbohydrate analysis and calorimetric measurements will be performed. The role of the microbiota in infant growth and development is often overlooked yet offers opportunities to advance neonatal care. The 'From Mum to Bum' study is the first study in which the effect of a preterm gut microbiota composition on its metabolic capacity and subsequent infant growth and development is investigated. By collecting human milk of all mothers, gastric aspirates of preterm infants and fecal samples of all infants at each timepoint, we can follow digestion of human milk from the breast of the mother throughout the gastrointestinal tract of the infant, or 'From Mum to Bum'.

An Expert Panel Statement on the Beneficial Effects of Human Milk Oligosaccharides (HMOs) in Early Life and Potential Utility of HMO-Supplemented Infant Formula in Cow's Milk Protein Allergy

This review by pediatric gastroenterology and allergy-immunology experts aimed to address the biological roles of human milk oligosaccharides (HMOs) and the potential utility of HMOs in prevention of allergy with particular emphasis on cow's milk protein allergy (CMPA). The participating experts consider HMOs amongst the most critical bioactive components of human milk, which act as antimicrobials and antivirals by preventing pathogen adhesion to epithelial cells, as intestinal epithelial cell modulators by enhancing maturation of intestinal mucosa and intestinal epithelial barrier function, as prebiotics by promoting healthy microbiota composition and as immunomodulators by modulating immune cells indirectly and directly. Accordingly, the participating experts consider the proposed link between HMOs and prevention of allergy to be primarily based on the impact of HMO on gut microbiota, intestinal mucosal barrier, immunomodulation and immune maturation. Along with the lower risk of respiratory and gastrointestinal infections, HMO-supplemented formulas seem to be promising alternatives in the management of CMPA. Nonetheless, the effects of individual as well as complex mixtures of HMO in terms of clear clinical and immunological effects and tolerance development need to be further explored to fully realize the immunomodulatory mechanisms and the potential for HMOs in prevention of allergic diseases and CMPA.

The Effect of Infant Formulas With 4 or 8 g/L GOS/FOS on Growth, Gastrointestinal Symptoms, and Behavioral Patterns: A Prospective Cohort Study

There is a lack of studies investigating the clinical benefits of prebiotic-supplemented infant formula. In this study, healthy infants that started, on medical recommendation, artificial feeding with one of 2 infant formulas containing 4 g/L of GOS/FOS (9:1) (IF4 group; n = 60) or 8 g/L of GOS/FOS (9:1) (IF8 group; n = 60) were followed for 30 days to the evaluation of growth and gastrointestinal symptoms. Exclusively breastfed infants (EBF; n = 60) were followed up as a reference. Both infant formulas supported adequate weight gain, however, IF4 formula promotes growth more similar to breastfed infants. There was no additional benefit of a dose higher than 4 g/L of GOS/FOS on gastrointestinal symptoms.

Hepatitis E Virus Immunopathogenesis

Hepatitis E virus is an important emerging pathogen producing a lethal impact on the pregnant population and immunocompromised patients. Starting in 1983, it has been described as the cause for acute hepatitis transmitted via the fecal–oral route. However, zoonotic and blood transfusion transmission of HEV have been reported in the past few decades, leading to the detailed research of HEV pathogenesis. The reason behind HEV being highly virulent to the pregnant population particularly during the third trimester, leading to maternal and fetal death, remains unknown. Various host factors (immunological, nutritional, hormonal) and viral factors have been studied to define the key determinants assisting HEV to be virulent in pregnant and immunocompromised patients. Similarly, chronic hepatitis is seen particularly in solid organ transplant patients, resulting in fatal conditions. This review describes recent advances in the immunopathophysiology of HEV infections in general, pregnant, and immunocompromised populations, and further elucidates the in vitro and in vivo models utilized to understand HEV pathogenesis.

Human Breast Milk Composition and Function in Human Health: From Nutritional Components to Microbiome and MicroRNAs

Human breast milk (HBM) is not only an indispensable source of nutrients for early human growth and development, supplying components that support infant growth and development, but also contains various essential immunologic components with anti-infectious activities and critical roles in the formation of immunity. It is also known that HBM contains its own unique microbiome, including beneficial, commensal, and potentially probiotic bacteria, that can contribute to infant gut colonization. In addition, HBM-derived extracellular vesicles, exosomes, and microRNA are attracting increasing interest for their potential to transfer to the infant and their role in infant development. In this article, we examine some of the various constituents in HBM and review the evidence supporting their associated health effects and their potential applications in human health.

Induction of SARS-CoV-2-Specific IgG and IgA in Serum and Milk with Different SARS-CoV-2 Vaccines in Breastfeeding Women: A Cross-Sectional Study in Northern Spain

Breastfeeding mothers were excluded from the clinical trials conducted for vaccines against SARS-CoV-2. Since the start of the vaccination, some doubts have arisen regarding its compatibility with breastfeeding. The aim of this study was to analyse the presence of anti-SARS-CoV-2 antibodies in breast milk and serum (IgG and IgA) of vaccinated breastfeeding women. The main variables of the observational study were: adverse related events after vaccination and determination of the presence of IgG and IgA isotypes antibodies in serum and in breast milk of vaccinated women against the SARS-CoV-2 antigens. Results: 110 breastfeeding mothers were included; 70 women (63.6%) were vaccinated with two doses of BNT162b2, 20 women (18.2%) with two doses of mRNA-1273, and 20 women (18.2%) with a single dose of ChAdOx1-S. Regarding adverse reactions and vaccine safety, 38 women had no adverse reactions; 20 (18.2%) had general malaise or adenopathies; 10 (9.1%) had a headache; and 7 (6.4%) had fever. When analysing IgG antibodies, significantly higher levels of antibodies were found in serum and breast milk from mothers vaccinated with BNT162b2 or mRNA-1273 vs. ChAdOx1-S (p < 0.001 and p = 0.001, respectively). Analysing IgA antibodies, significant differences were found when comparing mean values in serum from mothers vaccinated with BNT162b2 or mRNA-1273 vs. ChAdOx1-S (0.12, 0.16, and 0.02, respectively; p < 0.001) and breast milk of mothers vaccinated when comparing BNT16b2 vs. ChAdOx1-S. All vaccinated breastfeeding mothers had serum anti-S1 IgG antibodies in response to vaccination against SARS-CoV-2, regardless of the commercial vaccine administered. Conclusions: the anti-SARS-CoV-2 vaccines were well tolerated by the mothers and the breastfed infant. In addition, breastfeeding mothers offer their infants IgA and IgG isotype antibodies directed against SARS-CoV-2 protein S in breast milk.

The link between knowledge of the maternal diet and breastfeeding practices in mothers and health workers in Poland

BACKGROUND

There are multiple misconceptions concerning the breastfeeding mother's diet and its adverse impact on breast milk composition and the breastfed child's health, which might lead to breastfeeding cessation. Although prophylactic maternal dietary restrictions are not recommended, mothers all over the world are often recommended to avoid certain foods, due to cultural beliefs, social pressure and even outdated or ambiguous medical recommendations. In Poland, there is no systematic approach to breastfeeding education in the form of nationwide educational programs for particular social groups. It was estimated that in 2017 only 3-4% of Polish infants were exclusively breastfed at 6 months of age. The aim of this study was to recognize the scale of common dietary misconceptions among lactating mothers in Poland and to compare knowledge and opinions between medical staff and mothers who have ever breastfed a child. In addition, the paper is an attempt to identify factors contributing to the still current practice of recommending prophylactic dietary restrictions to breastfeeding mothers by medical staff.

METHODS

The study was conducted in Poland, in January - February 2019. The study used a diagnostic poll method and was conducted mainly in an electronic form. A total of 1159 completed questionnaires data were analyzed: 35.1% completed by medical staff and 64.9% by mothers in non-medical professions. Statistical calculations were conducted with Chi-square test, logistic regression and U Mann Whitney test (level of significance set at 0.05).

RESULTS

The respondents presented a good level of knowledge and predominantly assessed the questioned statements correctly. Duration of breastfeeding was found to be the main factor determining respondents' knowledge (p <  0.05). Concerning medical staff, the parity (p <  0.001) and applying an elimination diet when themselves breastfeeding (p <  0.001) had a significant impact on recommendation of prophylactic dietetic restrictions to the lactating women.

CONCLUSIONS

Regardless of a resonably good level of knowledge on maternal nutrition in the lactation period, both breastfeeding mothers and medical staff are still convinced of the beneficial effect of preventive dietary restrictions, which affects further lactational counselling and lactational performance.

Sex-specific associations of human milk long-chain polyunsaturated fatty acids and infant allergic conditions

BACKGROUND

Polyunsaturated fatty acids (PUFAs) may influence immune development. We examined the association of PUFAs in human milk with food sensitization and atopic dermatitis among breastfed infants.

METHODS

In a selected subgroup of 1109 mother-infant dyads from the CHILD Cohort Study, human milk was analyzed by gas-liquid chromatography to quantify PUFAs including arachidonic acid (ARA) and docosahexaenoic acid (DHA). At 1 year of age, food sensitization was determined by skin-prick testing for egg, peanut, cow's milk, and soybean, and atopic dermatitis was diagnosed by pediatricians. Logistic regression analyses controlled for breastfeeding exclusivity, family history of atopy, and other potential confounders.

RESULTS

Overall, 184 infants (17%) were sensitized to one or more food allergens and 160 (14%) had atopic dermatitis. Sex-specific associations were observed between these conditions and milk PUFAs. Girls receiving human milk with lower proportions of DHA had lower odds of food sensitization (aOR 0.35; 95% CI 0.12, 0.99 for lowest vs highest quintile), and a clear dose-dependent association was observed for the ARA/DHA ratio (aOR 2.98; 95% CI 1.10, 8.06 for lowest vs highest quintile). These associations were not seen in boys. Similar sex-specific tendencies were observed for atopic dermatitis.

CONCLUSIONS

Human milk PUFA proportions and their ratios are associated with infant atopic conditions in a sex-specific manner. In female infants, a higher ratio of ARA/DHA may reduce the risk of food sensitization and atopic dermatitis. Further research is needed to determine the underlying mechanisms and clinical relevance of this sex-specific association.

Analysis of the composition and antioxidant status of breast milk in women giving birth prematurely and on time

Background

Breastfeeding with mother’s milk is the best form of nutrition not only for newborn babies, but especially for premature babies, due to the health benefits of taking human food.

Objectives

The aim of the study was to examine the basic composition, cortisol concentration and antioxidant status of breast milk samples from women giving birth before 37 weeks of pregnancy and comparing it with milk samples from women giving birth after 37 weeks of pregnancy.

Methods

The material for the study was milk taken from women giving birth before and after 37 weeks of pregnancy. The basic composition of breast milk was determined using a MIRIS analyzer, cortisol concentration in samples by an enzyme-linked immunosorbent test and their total antioxidant status was assessed by DPPH and FRAP methods.

Results

It has been shown that the concentration of cortisol in samples of human milk in the group of women giving birth before 37 weeks was 13.95 ng / ml [4,71–86,84], while in the group of women giving birth after week 37 of pregnancy—10.31 ng / ml [2.35-39-02] (p = 0.014), while% inhibition of DPPH was 65.46% and 58.30%, respectively (p = 0.014).

Conclusions

Milk from women giving birth prematurely is qualitatively different from the milk of women giving birth on time. The total antioxidant status of preterm milk is higher than term milk, which promotes the development of premature babies. Higher cortisol levels in samples from women giving birth before 37 weeks of pregnancy may stimulate the digestive system.

Association of Socioeconomic Factors and Infant Nutrition Decisions: Breastfeeding and Type of Formula

Objective: Breastfeeding is considered the gold standard of infant feeding during the first year of life. However, many women experience difficulty breastfeeding and do not breastfeed to the extent that they initially planned. Our aims were to present factors influencing parents' choices of infant nutrition and to examine whether these choices are influenced by socioeconomic status (SES). Materials and Methods: We conducted a cross-sectional survey by interviewing mothers attending family health centers in various areas of Tel Aviv, Israel. Results: A total of 239 mothers participated in the survey. The choice of source of their infants' nutrition up to the age of 6 months was divided between exclusive breastfeeding, a combination of infant formula (IF) and breastfeeding, and exclusive IF (36%, 34%, and 30%, respectively). Exclusive breastfeeding was related to a higher SES (p = 0.02). The leading cause for combining IF in the infant's diet was maternal difficulty in breastfeeding (60%). The leading factors that influenced the choice of a specific IF product were continuation from the IF given in the hospital nursery (20%), advice from friends or family (20%) and cost (10%). There was a significant difference based on SES. A greater proportion of responders in a higher SES continued the IF that was supplied in the hospital, whereas lower SES parents tended to choose a formula according to its price (p < 0.05 for both). Conclusion: There is an overall lower prevalence of exclusive breastfeeding among low-income families. The maternal choice of the type of IF is associated with parental SES, with the choice of high SES mothers what was fed in the hospital and the choice of low SES related to price.

Risk factors for recurrent respiratory tract infection in preschool-aged children

BACKGROUND

We aimed to identify potential risk factors for recurrent respiratory tract infection among Chinese preschool-aged children, and further to construct a nomogram prediction model.

METHODS

This is a cross-sectional survey conducted in Beijing. Utilizing a stratified cluster random sampling strategy, a total of 7222 children from 20 kindergartens were enrolled. Data are analyzed by STATA software and R language.

RESULTS

Five independent factors were identified to be significantly associated with recurrent respiratory tract infection risk overall and by pathogenic sites. The significant odds of recurrent respiratory tract infection was 8.31 (95% confidence interval [CI]: 5.69-12.12, P < 0.001), 2.31 (2.06-2.58, P < 0.001), 1.72 (1.48-1.99, P < 0.001), 1.24 (1.08-1.43, P = 0.002), and 1.19 (1.09-1.31, P < 0.001) for asthma, allergy, initial use of antibiotics <6 months, breastfeeding duration <6 months, and maternal body mass index, respectively. Besides the leading role played by asthma, allergy, initial use of antibiotics, and breastfeeding might exert a graded, dose-dependent effect on recurrent respiratory tract infection susceptibility.

CONCLUSIONS

We have identified five potential risk factors for the risk of recurrent respiratory tract infection from 7222 preschool-aged Chinese children. Notably, asthma plays a leading role, and allergy, initial use of antibiotics, and breastfeeding might exert a graded, dose-dependent effect on recurrent respiratory tract infection susceptibility.

IMPACT

This is the first report of examining the joint contribution of multiple potential risk factors to recurrent respiratory tract infection among Chinese preschool-aged children. We have identified five potential risk factors for the risk of recurrent respiratory tract infection via analyzing survey data from 7222 preschool-aged Chinese children. Asthma plays a leading role, and allergy, initial use of antibiotics, and breastfeeding might exert a graded, dose-dependent effect on recurrent respiratory tract infection susceptibility.

Breastfeeding Prevalence in Austria according to the WHO IYCF Indicators-The SUKIE-Study

Breastfeeding and infant nutrition have an important impact on child health. The last representative data on breastfeeding in Austria was collected in 2006. The SUKIE-Study (Säuglings- und Kinderernährung) is a representative, longitudinal survey (online questionnaire) for participating mothers at four time points (14 days, four, six and 12 months post-partum). Questions on when other foods were first introduced were asked retrospectively. To ensure international comparisons, the World Health Organization’s definitions for breastfeeding, including “Infant and Young Child Feeding” indicators, were used. After eligibility screening, 1214 of 1666 invited mothers were included in the analysis. The initial breastfeeding rate was 97.5% and was reduced to 40.8% after 12 months. The rate of exclusive breastfeeding at one week of age was 55.5% and decreased to 1.9% after six months. Half of the infants received infant formula for the first time within the first three days of life (median). Out of the mothers that did wean breastfeeding in the first 12 months, the median duration was 27 weeks (right-censored data). Compared with 2006, an increase (93.2% to 97.5%) in the initial breastfeeding rate was found. However, other findings show that breastfeeding duration, including exclusive breastfeeding rates, need further improvement.

Maturation of the preterm gastrointestinal tract can be defined by host and microbial markers for digestion and barrier defense

Functionality of the gastrointestinal tract is essential for growth and development of newborns. Preterm infants have an immature gastrointestinal tract, which is a major challenge in neonatal care. This study aims to improve the understanding of gastrointestinal functionality and maturation during the early life of preterm infants by means of gastrointestinal enzyme activity assays and metaproteomics. In this single-center, observational study, preterm infants born between 24 and 33 weeks (n = 40) and term infants born between 37 and 42 weeks (n = 3), who were admitted to Isala (Zwolle, the Netherlands), were studied. Enzyme activity analyses identified active proteases in gastric aspirates of preterm infants. Metaproteomics revealed human milk, digestive and immunological proteins in gastric aspirates of preterm infants and feces of preterm and term infants. The fecal proteome of preterm infants was deprived of gastrointestinal barrier-related proteins during the first six postnatal weeks compared to term infants. In preterm infants, bacterial oxidative stress proteins were increased compared to term infants and higher birth weight correlated to higher relative abundance of bifidobacterial proteins in postnatal week 3 to 6. Our findings indicate that gastrointestinal and beneficial microbial proteins involved in gastrointestinal maturity are associated with gestational and postnatal age.

Breastfeeding intention and trait mindfulness during pregnancy

OBJECTIVE

Breastfeeding has been associated with many health benefits for both infant and mother. Trait mindfulness during pregnancy may have a beneficial impact on breastfeeding intention. The current study aimed to examine whether trait mindfulness during pregnancy was associated with antenatal breastfeeding intention.

DESIGN, SETTING AND PARTICIPANTS

The current study is part of a large prospective population-based cohort study among pregnant women in the south of the Netherlands.

MEASUREMENTS

A subsample of participants completed the Three Facet Mindfulness Questionnaire-Short Form at 22 weeks of pregnancy and a question on their breastfeeding intention at 32 weeks of pregnancy (N=790). Moreover, the Edinburgh Depression Scale and Tilburg Pregnancy Distress scale were completed at 32 weeks of pregnancy to assess levels of distress.

FINDINGS

Univariate analyses showed that women with breastfeeding intention during pregnancy had significantly higher scores on the mindfulness facet non-reacting (p<.001, medium effect size) and significantly lower scores on acting with awareness (p=.035, small effect size). A subsequent multiple logistic regression analysis showed that only non-reacting remained significantly associated with antenatal breastfeeding intention (OR=1.09, 95% CI [1.03, 1.15], p=.001), after controlling for confounders. Women who eventually initiated breastfeeding had significantly higher non-reacting scores (p<.001, small to medium effect size).

KEY CONCLUSIONS

The mindfulness facet non-reacting was found to be associated with antenatal breastfeeding intention. More research is needed to confirm our results, since the current study is one of the first assessing the possible relation of trait mindfulness during pregnancy and breastfeeding intention.

IMPLICATIONS FOR PRACTICE

Mindfulness-based programs during pregnancy could be helpful in improving non-reacting in pregnant women, which may enhance breastfeeding intention and ultimately the initiation of breastfeeding.

Human Milk Concentrations of Minerals, Essential and Toxic Trace Elements and Association with Selective Medical, Social, Demographic and Environmental Factors

This study aims to quantify concentrations of minerals and trace elements in human milk (HM) and infant formula (IF) and evaluate associations with medical, social, environmental, and demographic variables. A prospective, case series study of 170 nursing mothers was made. HM samples were obtained from full-term (colostrum, intermediate and mature HM) and preterm (mature HM) mothers. Variables of interest were assessed by a questionnaire. For comparison, IF samples (n = 30) were analyzed in a cross-sectional study. Concentrations of 35 minerals, essential and toxic trace elements were quantified, 5 for the first time: thallium in HM and IF; strontium in preterm HM; and gallium, lithium and uranium in IF. In preterm and full-term HM, levels of selenium (p < 0.001) were significantly lower than recommended and were associated with low birth weight (p < 0.002). Cesium and strontium concentrations were significantly higher than recommended (p < 0.001). Associations were observed between arsenic and residence in an urban area (p = 0.013), and between lead and smoking (p = 0.024) and well-water consumption (p = 0.046). In IF, aluminum, vanadium, and uranium levels were higher than in HM (p < 0.001); uranium, quantified for the first time, was 100 times higher in all types of IF than in HM. Our results indicate that concentrations of most trace elements were within internationally accepted ranges for HM and IF. However, preterm infants are at increased risk of nutritional deficiencies and toxicity. IF manufacturers should reduce the content of toxic trace elements.

Maternal Distress and Social Support Are Linked to Human Milk Immune Properties

Possible alterations of maternal immune function due to psychological stress may reflect immunoactive factor levels in breast milk. This study aimed to assess the association between maternal distress and breast milk levels of secretory IgA (SIgA), IgM, IgG, and lactoferrin (LF). We hypothesized that this association is moderated by maternal social support achieved from others during lactation. The study group included 103 lactating mothers and their healthy five-month-old infants. Maternal distress was determined based on the State Anxiety Inventory and the level of salivary cortisol. Social support was assessed using the Berlin Social Support Scales. Breast milk samples were collected to test for SIgA, IgM, IgG, and LF using the ELISA method. Milk immunoactive factors were regressed against maternal anxiety, social support, salivary cortisol, and infant gestational age using the general regression model. Maternal anxiety was negatively associated with milk levels of LF (β = -0.23, p = 0.028) and SIgA (β = -0.30, p = 0.004), while social support was positively associated with milk IgG (β = 0.25, p = 0.017). Neither anxiety nor social support were related to milk IgM. No association was found between the level of maternal salivary cortisol and immunoactive factors in milk. Our results suggest that maternal psychological wellbeing and social support may affect milk immune properties.

Bioactive Compounds in Infant Formula and Their Effects on Infant Nutrition and Health: A Systematic Literature Review

Infant formulas are an alternative to replace or supplement human milk when breastfeeding is not possible. The knowledge of human milk's bioactive compounds and their beneficial effects has attracted the interest of researchers in the field of infant nutrition, as well as researchers of technology and food sciences that seek to improve the nutritional characteristics of infant formulas. Several scientific studies evaluate the optimization of infant formula composition. The bioactive compound inclusion has been used to upgrade the quality and nutrition of infant formulas. In this context, the purpose of this systematic literature review is to assess the scientific evidence of bioactive compounds present in infant formulas (α-lactalbumin, lactoferrin, taurine, milk fat globule membrane, folates, polyamines, long-chain polyunsaturated fatty acids, prebiotics, and probiotics) and their effects on infant nutrition and health. Through previously determined criteria, studies published in the last fifteen years from five different databases were included to identify the advances in the optimization of infant formula composition. Over the last few years, there has been optimization of the infant formula composition, not only to increase the similarities in their content of macro and micronutrients but also to include novel bioactive ingredients with potential health benefits for infants. Although the infant food industry has advanced in the last years, there is no consensus on whether novel bioactive ingredients added to infant formulas have the same functional effects as the compounds found in human milk. Thus, further studies about the impact of bioactive compounds in infant nutrition are fundamental to infant health.

Human Milk from Previously COVID-19-Infected Mothers: The Effect of Pasteurization on Specific Antibodies and Neutralization Capacity

BACKGROUND

Since the outbreak of coronavirus disease 2019 (COVID-19), many put their hopes in the rapid availability of effective immunizations. Human milk, containing antibodies against syndrome coronavirus 2 (SARS-CoV-2), may serve as means of protection through passive immunization. We aimed to determine the presence and pseudovirus neutralization capacity of SARS-CoV-2 specific IgA in human milk of mothers who recovered from COVID-19, and the effect of pasteurization on these antibodies.

METHODS

This prospective case control study included lactating mothers, recovered from (suspected) COVID-19 and healthy controls. Human milk and serum samples were collected. To assess the presence of SARS-CoV-2 antibodies we used multiple complementary assays, namely ELISA with the SARS-CoV-2 spike protein (specific for IgA and IgG), receptor binding domain (RBD) and nucleocapsid (N) protein for IgG in serum, and bridging ELISA with the SARS-CoV-2 RBD and N protein for specific Ig (IgG, IgM and IgA in human milk and serum). To assess the effect of pasteurization, human milk was exposed to Holder (HoP) and High Pressure Pasteurization (HPP).

RESULTS

Human milk contained abundant SARS-CoV-2 antibodies in 83% of the proven cases and in 67% of the suspected cases. Unpasteurized milk with and without these antibodies was found to be capable of neutralizing a pseudovirus of SARS-CoV-2 in (97% and 85% of the samples respectively). After pasteurization, total IgA antibody levels were affected by HoP, while SARS-CoV-2 specific antibody levels were affected by HPP. Pseudovirus neutralizing capacity of the human milk samples was only retained with the HPP approach. No correlation was observed between milk antibody levels and neutralization capacity.

CONCLUSIONS

Human milk from recovered COVID-19-infected mothers contains SARS-CoV-2 specific antibodies which maintained neutralization capacity after HPP. All together this may represent a safe and effective immunization strategy after HPP.

Influence of Human Milk on Very Preterms' Gut Microbiota and Alkaline Phosphatase Activity

The FEEDMI Study (NCT03663556) evaluated the influence of infant feeding (mother's own milk (MOM), donor human milk (DHM) and formula) on the fecal microbiota composition and alkaline phosphatase (ALP) activity in extremely and very preterm infants (≤32 gestational weeks). In this observational study, preterm infants were recruited within the first 24 h after birth. Meconium and fecal samples were collected at four time points (between the 2nd and the 26th postnatal days. Fecal microbiota was analyzed by RT-PCR and by 16S rRNA sequencing. Fecal ALP activity, a proposed specific biomarker of necrotizing enterocolitis (NEC), was evaluated by spectrophotometry at the 26th postnatal day. A total of 389 fecal samples were analyzed from 117 very preterm neonates. Human milk was positively associated with beneficial bacteria, such as Bifidobacterium, Bacteroides ovatus, and Akkermancia muciniphila, as well as bacterial richness. Neonates fed with human milk during the first week of life had increased Bifidobacterium content and fecal ALP activity on the 26th postnatal day. These findings point out the importance of MOM and DHM in the establishment of fecal microbiota on neonates prematurely delivered. Moreover, these results suggest an ALP pathway by which human milk may protect against NEC.

Impact of an Infant Formula Containing a Novel Fat Blend (Cow's Milk Fat, Fish and Vegetable Oil) and Prebiotics on Stool Fatty Acid Soaps and Erythrocyte Fatty Acid Profiles in Full-Term Healthy Newborns

INTRODUCTION

Recently, new commercial infant formulas have been composed considering novel fat blends and oligosaccharides to better resemble the fatty acid (FA) composition and stereospecific distribution (e.g., increased amount of ß-palmitate) as well as probiotics content of human breast milk. We hypothesized that these newly composed infant formulas may decrease fecal FA soap excretion and may positively affect erythrocyte FA profiles compared with regular formulas.

METHODS

Healthy infants were randomly assigned to receive a high-sn-2-palmitate formula (>25% of the PA is esterified to the sn-2 position of the glycerol backbone, verum: n = 30) or a "standard" formula containing <10% of PA in sn-2 position and no oligosaccharides (control: n = 27); a non-randomized group of breast-fed infants served as control. Anthropometric data of the infants (body weight, recumbent length, and head circumference) were recorded at inclusion (visit 1) and 6 and 12 weeks after onset of intervention (visits 2 and 3). Blood samples for erythrocyte FA analysis (gas chromatography) were taken at visits 1 and 2; stool samples were collected at visit 2.

RESULTS

Quantitative formula intake (mL/kg body weight × day) at visit 2 (verum: 155 ± 30, control: 164 ± 30) and visit 3 (verum: 134 ± 26, control: 134 ± 21) was comparable. Six weeks after onset of intervention, stool total FA soaps, palmitate soaps, and total FAs were similar in both formula-fed groups but significantly higher than in breast-fed infants. During the 6-week intervention, erythrocyte palmitate decreased significantly from baseline in all 3 groups with no group differences (verum: 29.20 ± 1.17 to 27.12 ± 0.66, control: 29.88 ± 2.00 to 27.01 ± 0.94, breast-fed: 30.20 ± 0.86 to 26.84 ± 0.98). For selected FAs, significant changes over time in verum and control group were obvious but without formula effects. Some variations in the FA profile of breast-fed infants compared to both verum and control groups were observed.

CONCLUSIONS

In contrast to our hypothesis, feeding a newly composed infant formula based on a fat blend with 25% of PA in the sn-2 position of triacylglycerols and supplemented with a prebiotic could not decrease insoluble FA soap excretion compared with a standard product; in this respect, breastfeeding is obviously the best choice. Surprisingly, erythrocyte FA profiles were comparable in formula-fed and breast-fed infants; obvious alterations in FA composition of the respective fat sources and structure did not affect FA incorporation into membranes. Caution should be, however, exercised in drawing robust conclusions in the absence of larger, adequately powered intervention studies.

Influence of different breast expression techniques on human colostrum macronutrient concentrations

OBJECTIVE

To evaluate the effects of breast expression methods on macronutrient and caloric concentrations in human colostrum.

STUDY DESIGN

A cross-sectional study in which colostrum samples were collected simultaneously from each breast using different milk expression methods, including manual expression or electric pumping, assigned by simple randomization. Macronutrients were measured by infrared spectroscopy, and their concentrations were compared by the Wilcoxon test.

RESULTS

Ninety-six samples from each breast of selected donors were evaluated. There were no differences in carbohydrate (6.1 vs. 6.1 g/dL; p: 0.218) and protein (2.1 vs. 2.1 g/dL; p: 0.772) concentrations between the samples collected by manual expression and electric pumping. However, in those collected by manual expression, lipid concentrations (2.6 vs. 2.2 g/dL; p < 0.001) and caloric content (60 vs. 57 Kcal/dL; p = 0.001) were higher.

CONCLUSIONS

Colostrum collected by hand expression had a higher lipid concentration and caloric content than that collected by an electric pump.

Antioxidative Molecules in Human Milk and Environmental Contaminants

Breastfeeding provides overall beneficial health to the mother-child dyad and is universally recognized as the preferred feeding mode for infants up to 6-months and beyond. Human milk provides immuno-protection and supplies nutrients and bioactive compounds whose concentrations vary with lactation stage. Environmental and dietary factors potentially lead to excessive chemical exposure in critical windows of development such as neonatal life, including lactation. This review discusses current knowledge on these environmental and dietary contaminants and summarizes the known effects of these chemicals in human milk, taking into account the protective presence of antioxidative molecules. Particular attention is given to short- and long-term effects of these contaminants, considering their role as endocrine disruptors and potential epigenetic modulators. Finally, we identify knowledge gaps and indicate potential future research directions.

The Influence of Parental Dietary Behaviors and Practices on Children's Eating Habits

Poor dietary habits established during childhood might persist into adulthood, increasing the risk of developing obesity and obesity-related complications such as Type 2 Diabetes Mellitus. It has been found that early modifications in eating habits, especially during childhood, might promote health and decrease the risk of developing diseases during later life. Various studies found a great influence of parental dietary habits on dietary behaviors of their children regardless of demographic characteristics such as gender, age, socioeconomic status and country; however, the exact mechanism is still not clear. Therefore, in this review, we aimed to investigate both parents’ and children’s dietary behaviors, and to provide evidence for the potential influence of parents’ dietary behaviors and practices on certain children’s eating habits. Family meals were found to contribute the most in modeling children’s dietary habits as they represent an important moment of control and interaction between parents and their children. The parental practices that influenced their children most were role modeling and moderate restriction, suggesting that the increase of parental encouragement and decrease of excessive pressure could have a positive impact in their children’s dietary behaviors. This narrative review highlights that parental child-feeding behaviors should receive more attention in research studies as modifiable risk factors, which could help to design future dietary interventions and policies to prevent dietary-related diseases.

Breast-feeding promotion in hospitals and prospective breast-feeding rates during the first year of life in two national surveys 1997-1998 and 2017-2019 in Germany

OBJECTIVES

The present study aimed to assess the current state of breast-feeding promotion in hospitals and the prevalence of breast-feeding during the first year of life in Germany and to compare the results with a study 20 years earlier.

DESIGN

In the studies on 'breast-feeding and infant nutrition in Germany' named 'SuSe', a cross-sectional survey in hospitals was combined with a subsequent prospective survey of breast-feeding and infant nutrition during the first year of life (0·5, 2, 4, 6 and 12 months after birth) in mother-infant pairs who were recruited in the hospitals. Written questionnaires and phone calls were used in SuSe I and web-based questionnaires in SuSe II. Breast-feeding promotion and prevalence were evaluated using recommendations from the WHO and the UNICEF.

SETTING

Two nationwide surveys SuSe I (1997-1998) and SuSe II (2017-2019).

PARTICIPANTS

In SuSe I, 177 hospitals and 1717 mother-infant pairs and in SuSe II 109 hospitals and 962 mother-infant pairs were included.

RESULTS

In SuSe II, hospitals implemented seven of the WHO 'Ten Steps to Successful Breastfeeding' to a greater extent than the hospitals in SuSe I. More mothers exclusively breastfed for 4 months (57 % v. 33 %) and continued breast-feeding until 6 (78 % v. 48 %) and 12 months (41 % v. 13 %). In both studies, exclusive breast-feeding decreased between 4 and 6 months of age due to the introduction of complementary feeding.

CONCLUSIONS

In Germany, breast-feeding habits have come closer to the recommendations over the last 20 years.

Nutritional Education Is an Effective Tool in Improving Beverage Assortment in Nurseries in Poland

The aim of the study was to assess the impact of education on improving the assortment of beverages served in nurseries in Poland. This analysis focused on beverages served to children with meals and between meals. We examined: water, tea, juices, soft/fruit drinks, compote, milk, cocoa, and coffee substitute. The study involved 93 nurseries enrolled in the Eating Healthy, Growing Healthy project and was conducted from 2015 to 2017. Nutritional education was carried out by dieticians or nutritionists and included 24 h of lectures given to the staff of nurseries. Training was conducted in a form of workshops that were divided into 12 topics. Additionally, consultations regarding infants and young children nutrition were available to the staff. Typically, education training was completed within 1–2 months in each nursery. The effectiveness of education was verified based on data on beverage supply in 186 ten-day menus, 1860 daily inventory reports before (at baseline), and 3–6 months after staff training (post baseline). Data were analyzed in a total group, and separately for public and non-public nurseries. Statistical analyses for categorical variables were done with Chi² Pearson test. The differences were considered significant at p < 0.05. After education, a significant increase in the supply of water as a beverage served with meals was observed in all nurseries (68% vs. 87%; p = 0.002), both in public (72% vs. 90%, p = 0.036) and non-public (62% vs. 84%, p = 0.017) ones. Moreover, a decrease in served tea was noted: in all nurseries (71% vs. 44%, p < 0.001) and in public nurseries (77% vs. 42%, p < 0.001). Water was available between meals in almost all nurseries. Nutritional education for staff is an important tool for improving adherence to the nutritional recommendation in the case of core beverage supply in Polish nurseries.

Are Mothers Certain About Their Perceptions of Recalled Infant Feeding History?

INTRODUCTION

Maternal recall of infant feeding, a potential measurement bias, is used to identify the relationship between mothers' own milk (MOM) feeding and subsequent health outcomes. This study describes maternal recall certainty of MOM feedings at four time periods.

METHOD

In this secondary analysis, mothers of children ages 4-36 months describe infants' MOM feeding and rate certainty of their recall.

RESULTS

MOM was the first feeding for 78.5% of infants and received by 83% the first week, 85% the first month, and 62% the fourth month. Ratings of recall certainty were > 95% for each time period. Recall certainty was significantly different for four time periods (χ² = 9.67, p = 0.02), with no two periods significantly different in post hoc analyses.

DISCUSSION

Maternal recall certainty of infant feeding was high regardless of elapsed time. Measuring maternal recall certainty may be useful in clinical practice and studies linking MOM exposure to subsequent health outcomes.

Improved exclusive breastfeeding rates in preterm infants after a neonatal nurse training program focusing on six breastfeeding-supportive clinical practices

BACKGROUND

Early breast milk expression, prolonged skin-to-skin contact, rooming-in, use of test-weighing and minimizing use of pacifiers are positively associated with exclusive breastfeeding of preterm infants, whereas use of nipple shields is negatively associated.

AIM

To test whether a training program for neonatal nurses with a focus on these six breastfeeding-supportive clinical practices affects the rate of preterm infants exclusively breastfed at discharge to home, the postmenstrual age at establishment of exclusive breastfeeding, and maternal self-reported use of the practice in the neonatal intensive care unit, the.

METHODS

A quasi-experimental multi-centre intervention study from 2016-2019 including a control group of 420 preterm mother-infant dyads, an intervention with a training program for neonatal nurses and implementation of weekly breastfeeding meetings for neonatal nurses, and an intervention group of 494 preterm mother-infant dyads.

RESULTS

Significantly more preterm infants in the intervention group were exclusively breastfed at discharge to home (66.6%) than in the control group (58.1%) p = 0.008. There was no significant difference in postmenstrual age at establishment of exclusive breastfeeding between control and intervention group (37.5 vs.37.8 weeks, p = 0.073). Compared to the control group the number of infants continuing daily skin-to-skin contact after incubator care increased (83.2% vs. 88.3%, p = 0.035), infants using a nipple shield decreased (61.8% vs. 54.2%, p = 0.029), and the number of mothers initiating breast milk expression before six hours post-partum increased (32.6% vs. 42.4%, p = 0.007). There was a significant correlation between percentage of neonatal nurses participating in the breastfeeding training program and changes in exclusive breastfeeding rates (Pearson Correlation 0.638, p = 0.047).

CONCLUSION

Exclusive breastfeeding rates in preterm infants and maternal self-reported use of breastfeeding-supportive practices increased by training neonatal nurses in the six clinical practices. It is important to include all nurses in the breastfeeding training program to ensure positive effect on exclusive breastfeeding rates.

The Triad Mother-Breast Milk-Infant as Predictor of Future Health: A Narrative Review

The benefits of human milk for both mother and infant are widely acknowledged. Human milk could represent a link between maternal and offspring health. The triad mother-breast milk-infant is an interconnected system in which maternal diet and lifestyle might have effects on infant's health outcome. This link could be in part explained by epigenetics, even if the underlining mechanisms have not been fully clarified yet. The aim of this paper is to update the association between maternal diet and human milk, pointing out how maternal diet and lifestyle could be associated with breast-milk composition, hence with offspring's health outcome.

Quality Assurance in Lactation: Reliability of OM-6050 Station System to Test Mother's Milk Osmolality

BACKGROUND

Mother's own milk does not provide enough nutrients to feed a preterm baby born before 32 weeks' gestation; therefore, human milk fortifiers are needed. However, human milk fortifiers increase the osmolality, and enteral administration of high osmolality fluids has been associated with gastrointestinal symptoms. For this reason, it is necessary for laboratories to have a validated system in order to measure human milk osmolality.

RESEARCH AIM

The aim of this study was to validate the OM-6050 Station System for measuring the osmolality of fortified mother's milk samples.

METHODS

Osmolality was measured using the osmometer OM-6050 Station System. Milk samples from healthy mothers (N = 3) unfortified and with two fortifiers (Almirón Fortifier^® or NAN FM85^®), as well as a nutritional supplement (Duocal MCT^®) were used in the validation study through precision and linearity analysis.

RESULTS

In the precision study the mean intra-assay coefficient of variation was 1.2% and 1.7% for mother's milk and fortified mother's milk, respectively. The mean inter-assay coefficient of variation was ≤ 1% in both cases. In the linearity study the regression analysis had a linear response to fortified mother's milk osmolality between 294 mOsm/kg and 539 mOsm/kg.

CONCLUSION

The osmometer OM-6050 Station was reliable for determining the osmolality of fortified and unfortified mother's milk. It may be useful in the clinical practices within Neonatal Intensive Care Units.

Differences in maternal characteristics and their associations with breastfeeding attitudes among primiparous mothers

BACKGROUND

The benefits of breastfeeding are well documented, yet substantially below half of all mothers globally meet the recommendation to exclusively breast-feed for 6 months.

OBJECTIVE

This study aimed to examine whether there were differences in maternal factors, including maternal characteristics and breastfeeding attitudes, between those who were eligible versus non-eligible to be included in a randomised trial, as exclusive breastfeeding was the eligibility criteria for the trial. It also aimed to investigate associations between maternal factors and breastfeeding attitudes.

METHOD

Primiparous pregnant mothers (n=88) completed questionnaires on demographic factors including maternity care and breastfeeding attitude using self-administered questionnaire and Iowa Infant Feeding Attitude Scale (IIFAS). Two weeks post-birth, mothers were screened for eligibility to be included in a randomised trial including assessing for exclusive breastfeeding (EBF). Findings were compared between inclusion (all EBF mothers) and exclusion groups (non-EBF).

RESULTS

Inclusion group mothers were significantly younger than those in the exclusion group (26.7±2.8 v 28.5±2.5, p=0.007) and the majority had their husband as the primary maternity care person after birth (X²=12.8, p=0.01). Inclusion group mothers had a more positive perception toward breastfeeding in public and at work on the IIFAS scale (p<0.05). The overall IIFAS score was positively associated with higher breastfeeding confidence (r=0.285, p=0.008), education levels (r=0.31, p=0.003), household income (r=0.32, p=0.003), and age (r=0.28, p=0.008).

CONCLUSION

EBF mothers (inclusion group) tend to be younger, had husband as primary care, and have more positive perception towards breastfeeding outside home. Overall, maternal characteristics and paternal support could influence breastfeeding practices and should be targeted for future intervention. Maternal attitude and perceptions about breastfeeding in public could be improved to encourage exclusive breastfeeding.

How Do We Manage Breastfeeding During the COVID-19 Pandemic?

The COVID-19 pandemic is causing global disturbances and creating many questions in every aspect of life. Since it influences health in multiple ways, including sexual and reproductive health, publishing in all of these areas has increased lately. One aspect that requires basing on scientific evidence is breastfeeding. There are some controversies in the literature on the breastfeeding management in confirmed COVID-19 mothers. Breast milk is excellent for the infant's nutritional needs and growth, because it includes all of the nutrients an infant requires. It promotes the immature immune system of the infant and reinforces defense mechanisms against infectious and other agents during the breastfeeding period. While limited clinical research is available, we can build on what we know about breastfeeding and previous similar outbreaks to plan and manage this crisis. The aim of this chapter is to provide pediatricians with further guidance on breastfeeding and associated safety measures during the COVID-19 crisis, particularly in instances where a mother has or may have COVID-19. This will also be a benefit to future epidemics and pandemics.

Characterization of Infant Feeding Practices and Related-Family Characteristics in the French Nationwide ELFE Birth Cohort

Family characteristics such as education level or income are related to infant feeding practices. This study aimed to characterize infant feeding practices and investigate their associations with family characteristics. Analyses were performed with data from a French nationwide cohort, Etude Longitudinale Française depuis l’Enfance (ELFE). Feeding practices were characterized by two methods, a principal component analysis and a hierarchical ascendant classification (n = 8922). This characterization was conducted in three steps: considering firstly only introduction of main food groups, then also food pieces and finally adding the type of complementary food. The associations between family characteristics and the infant feeding patterns or clusters were tested by linear or multinomial regressions (n = 7556). Besides breastfeeding duration and age of first introduction of complementary foods, it appeared also important to consider specific food groups such as sweetened beverages and cow’s milk, and the introduction of food pieces, to describe feeding practices. Recommended feeding practices (longer breastfeeding, complementary food in the right period) were related to higher maternal age and education level, so was migration status, the presence of older children, low income or the mothers’ attendance to pre-birth preparation classes. The interrelations between feeding practices and family characteristics must be considered when examining the influence of feeding practices on child’s health.

Multiple Micronutrients, Lutein, and Docosahexaenoic Acid Supplementation during Lactation: A Randomized Controlled Trial

Breastfed infants require an adequate supply of critical nutrients for growth, tissue functions, and health. Recommended intakes for several nutrients are considerably higher in lactating than non-lactating women but are not always met with habitual diets. We report a randomized, double-blind clinical trial in 70 healthy lactating women in Germany evaluating the effects of supplementation with multiple micronutrients, lutein, and docosahexaenoic acid (DHA) compared to placebo on maternal nutrient status and milk composition. The primary endpoint was the effect on the change of human milk DHA content (as a proportion of total milk fatty acids) during 12 weeks of supplementation. Maternal blood and milk biomarkers were measured as secondary endpoints. Supplementation increased maternal milk DHA by 30% compared to a decline in the placebo group. Supplementation also increased maternal blood DHA (17%), eicosapentaenoic acid (4%), 25-OH-vitamin D (24%), vitamin B12 (12%), lutein (4%), and beta carotene (49%), while homocysteine decreased. No significant difference in the number of adverse events was observed between supplementation and placebo groups. In conclusion, multi-micronutrient supplementation was safe and increased maternal blood and milk concentrations of selected nutrients in healthy women.

Lactobacillus Bacteria in Breast Milk

Breast milk is an optimal food for infants and toddlers. The composition of breast milk adapts to the needs of the developing organism, satisfying nutritional needs at an early stage of growth and development. The results of research to date have shown that breast milk is the best food for a child, containing not only nutrients but also biologically active substances that aid in the optimal, proper growth and development of infants. Among the many components of breast milk, an important element is the probiotic microflora, including bacteria of the genus Lactobacillus spp. These organisms exert a multidirectional, health-promoting effect on the body of children who consume breast milk. The number of lactic acid bacteria, including Lactobacillus, colonizing the breast milk environment and their species diversity varies and depends on many factors, both maternal and environmental. Breast milk, as a recommended food for infants, is an important source of probiotic microflora. The aim of this study was to present the current understanding of probiotic bacteria of the genus Lactobacillus present in breast milk.

Promoting Breastfeeding and Interaction of Pediatric Associations With Providers of Nutritional Products

Pediatric associations have been urged not to interact with and not to accept support from commercial providers of breast milk substitutes (BMSs), based on the assumption that such interaction would lead to diminished promotion and support of breastfeeding. The leadership of seven European pediatric learned societies reviewed the issue and share their position and policy conclusions here. We consider breastfeeding as the best way of infant feeding and strongly encourage its active promotion, protection, and support. We support the World Health Organization (WHO) Code of Marketing of BMSs. Infant formula and follow-on formula for older infants should not be advertised to families or the public, to avoid undermining breastfeeding. With consistently restricted marketing of BMSs, families need counseling on infant feeding choices by well-informed pediatricians. Current and trustworthy information is shared through congresses and other medical education directed and supervised by independent pediatric organizations or public bodies. Financial support from commercial organizations for congresses, educational, and scientific activities of pediatric organizations is an acceptable option if scientific, ethical, societal, and legal standards are followed; any influence of commercial organizations on the program is excluded, and transparency is ensured. Public-private research collaborations for improving and evaluating pharmaceuticals, vaccines, medical devices, dietetic products, and other products and services for children are actively encouraged, provided they are guided by the goal of enhancing child health and are performed following established high standards. We support increasing investment of public funding for research aiming at promoting child health, as well as for medical education.

National Recommendations for Infant and Young Child Feeding in the World Health Organization European Region

OBJECTIVES

Complementary feeding should provide a healthy diet with critical nutrients for growth and development. Information is limited on child and infant feeding recommendations within the World Health Organization (WHO) European Region.

METHODS

The WHO Regional Office for Europe and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) performed a survey of national recommendations on infant and young child nutrition aimed at national government departments of health and national paediatric experts. Questions addressed national recommendations on breast-feeding and complementary feeding.

RESULTS

Information was available from 48 of the 53 Member States. Forty-five of 48 countries (94%) have national recommendations on infant and young child feeding, of which 41 are endorsed by official public health authorities. Regarding introduction of complementary feeding, 25 countries (out of 34, 74%) recommend 6 months of age as the ideal age. The earliest age of introduction recommended varies from 4 to 5 months in (31/38 countries, 82%) to 6 months (6/38, 16%) and 7 months (1/38, 2.6%). The recommended meal composition varies widely; introduction of iron-rich foods (meat, fish, eggs) at the age of 6 months is recommended in 30 out of 43 countries, whereas 13 (30%) recommend later introduction.

CONCLUSIONS

National infant feeding recommendations vary widely between studied countries and partly differ from international recommendations. Too early introduction of complementary feeding can reduce duration of exclusive breast-feeding (EBF). Too late introduction of iron-rich complementary foods might increase anemia risk and adversely affect child development. A review and further harmonization of national recommendations appears desirable.

The Impact of Milk and Its Components on Epigenetic Programming of Immune Function in Early Life and Beyond: Implications for Allergy and Asthma

Specific and adequate nutrition during pregnancy and early life is an important factor in avoiding non-communicable diseases such as obesity, type 2 diabetes, cardiovascular disease, cancers, and chronic allergic diseases. Although epidemiologic and experimental studies have shown that nutrition is important at all stages of life, it is especially important in prenatal and the first few years of life. During the last decade, there has been a growing interest in the potential role of epigenetic mechanisms in the increasing health problems associated with allergic disease. Epigenetics involves several mechanisms including DNA methylation, histone modifications, and microRNAs which can modify the expression of genes. In this study, we focus on the effects of maternal nutrition during pregnancy, the effects of the bioactive components in human and bovine milk, and the environmental factors that can affect early life (i.e., farming, milk processing, and bacterial exposure), and which contribute to the epigenetic mechanisms underlying the persistent programming of immune functions and allergic diseases. This knowledge will help to improve approaches to nutrition in early life and help prevent allergies in the future.

More than Nutrition: Therapeutic Potential of Breast Milk-Derived Exosomes in Cancer

Human breast milk (HBM) is an irreplaceable source of nutrition for early infant growth and development. Breast-fed children are known to have a low prevalence and reduced risk of various diseases, such as necrotizing enterocolitis, gastroenteritis, acute lymphocytic leukemia, and acute myeloid leukemia. In recent years, HBM has been found to contain a microbiome, extracellular vesicles or exosomes, and microRNAs, as well as nutritional components and non-nutritional proteins, including immunoregulatory proteins, hormones, and growth factors. Especially, the milk-derived exosomes exert various physiological and therapeutic function in cell proliferation, inflammation, immunomodulation, and cancer, which are mainly attributed to their cargo molecules such as proteins and microRNAs. The exosomal miRNAs are protected from enzymatic digestion and acidic conditions, and play a critical role in immune regulation and cancer. In addition, the milk-derived exosomes are developed as drug carriers for delivering small molecules and siRNA to tumor sites. In this review, we examined the various components of HBM and their therapeutic potential, in particular of exosomes and microRNAs, towards cancer.

Respiratory Complications in Children Hospitalized with Respiratory Syncytial Virus Infection

The goal of this study was to define the prevalence of respiratory complications, other than bronchiolitis, such as pneumonia, acute otitis media, and conjunctivitis in children treated in a hospital due to respiratory syncytial virus (RSV) infection, with reference to the plausible risk factors. The study included 111 children, aged up to 22 months (median 3 months). Complications were observed in 68 (61%) children, with 32 (29%) children presenting more than one. The most frequent complication was acute otitis media in 53 (48%), pneumonia in 37 (33%), and conjunctivitis in 12 (11%) out of the 111 children. Children with complications were older than those without complications and had fever that lasted for a significantly longer time, both before and during hospitalization, and the fever was stronger. They also presented a significantly lower breathing rate at admission. The age over 3 months was a single risk factor associated with the development of otitis media (OR = 9.8, 95%CI: 3.6-26.7) and pneumonia (OR = 2.8, 95%CI: 1.1-7.3). Other factors such as prematurity, birth weight below 2500 g, exposure to tobacco smoke during pregnancy, and the cessation of breastfeeding below age 6 months were statistically irrelevant to this end. We conclude that complications are very frequent in hospitalized children with RSV infection and their risk increases with the infant age.

Factors associated with duration of breastfeeding in Spain: a cohort study

Background

Factors associated with duration of breastfeeding have been usually studied at specific times after birth. Little is known about how much time is added to breastfeeding by each associated factor.

Methods

A cohort of 969 mother-child dyads was followed-up for twelve months at the Marqués de Valdecilla University Hospital, Spain, in 2018. Data on mother characteristics, pregnancy, delivery and children characteristics were obtained from medical records. Length of breastfeeding was reported by the mothers and recorded in paediatric medical record at hospital discharge and 2, 4, 6, 9 and 12 months of life. Factors associated with duration of breastfeeding were analysed via multivariate Weibull regression parameterized as accelerated time of failure. Results are presented as time ratios.

Results

About four out of five children were breastfed at hospital discharge, although this proportion dropped to 65% in children born from smoker women, 70% in preterm children and 68% in neonates weighting less than 2500 g. Mother’s age was associated with longer breastfeeding, adding 2% more breastfeeding time per year (adjusted time ratio 1.02; 95% confidence interval 1.00, 1.04). Children born from mothers with university studies were breastfed 53% more time than those born from mothers with primary studies (adjusted time ratio 1.53; 95% confidence interval 1.21, 1.95); smoking in pregnancy decreased length of breastfeeding by 41% (adjusted time ratio 0.59; 95% confidence interval 0.46, 0.76). Other factors associated with longer breastfeeding were single pregnancy and newborn weight over 2500 g.

Conclusions

Analysing factors associated with duration of breastfeeding as time parameters allows us to quantify the amount of time gained or lost by each factor, which could make it easier to evaluate the relevance of programmes directed to promote facilitating breastfeeding factors.

The Effect of Prolonged Freezing and Holder Pasteurization on the Macronutrient and Bioactive Protein Compositions of Human Milk

Introduction: Human donor milk is widely used to feed premature and sick newborns when the milk of their own mothers is insufficient. All treatment processes involving human milk affect its composition. The aim of this study was to assess changes in the macronutrients and bioactive protein (lactoferrin and lysozyme) content in human milk caused by freezing and Holder pasteurization. Materials and Methods: Milk samples were collected from 42 mothers 14-16 days after delivery. Each sample was divided into two parts and tested twice for macronutrient content, once upon being freshly collected and again after freezing at -40°C, thawing and Holder pasteurization. The lysozyme and lactoferrin concentrations were first determined in the unpasteurized thawed human milk after it was stored frozen at -80°C for up to 10 months and again after Holder pasteurization. The macronutrient concentrations were determined by midinfrared spectrophotometry, and enzyme-linked immunosorbent assay was used to measure the lysozyme and lactoferrin concentrations. Results: Freezing and Holder pasteurization had no significant effects on the macronutrient concentrations. The mean lactoferrin content before and after pasteurization was 2.5 ± 1.07 and 0.03 ± 0.03 mg/mL, respectively (p < 0.001), and the lysozyme content was 19.57 ± 20.11 and 12.62 ± 14.14 μg/mL, respectively (p = 0.007). Conclusions: Freezing and Holder pasteurization did not decrease the nutritional value of human milk but caused considerable loss of lactoferrin and lysozyme. New methods for treating human milk are needed that ensure the destruction of pathogenic microorganisms while retaining the biological and nutritional value of the milk. The Clinical Trial Registration number: NCT04382989.

Infant drug exposure via breast milk

More than half of women take medications during breastfeeding, predisposing their infants to medication exposure via breast milk. As a result, adverse drug reactions may emerge in the infant, although they are rarely reported. Disposition of maternal drugs in breast milk is described with several key parameters, which include relative infant dose (RID): infant drug intake via milk (weight- and time-adjusted) expressed as a percentage of the similarly adjusted mother's dose. Most drugs show RID values of <10%, indicating that drug concentrations in infant serum do not reach a level known to be therapeutic in adults unless drug clearance is markedly lower than the adult level on a weight basis. RID is a function of milk-to-(maternal) plasma drug concentration ratio (MP ratio) and maternal drug clearance. Therefore, MP ratio between drugs must be interpreted not by itself but with maternal drug clearance of each drug. This is why some drugs such as phenobarbital show an MP ratio of <1 but an RID as high as 50-70%, while morphine shows an MP ratio of 2 but an RID in the range of 5%. Using RID, we interpreted case reports of infant adverse outcomes, and we observed cases with relatively low infant serum concentrations of drug, consistent with low RID, as well as those with near- or above-adult therapeutic serum concentrations, with or without increased drug intake (i.e. high RID). It is important to consider both pharmacokinetic and pharmacodynamic factors in interpreting adverse outcomes in infants breastfed by a mother taking medications.

Impact of Infant and Maternal Factors on Energy and Macronutrient Composition of Human Milk

The present study investigates the influence of selected infant and maternal factors on the energy and macronutrient composition of mature human milk (HM). The study enrolled 77 mothers at 4-8 weeks postpartum. Each mother provided 1 sample of HM. Each extracted HM sample was formed by mixing four subsamples of HM, each of which were obtained in one predefined 6-h periods of the day. Among maternal factors, the analysis included: anthropometric data before and after pregnancy; weight gain in pregnancy; body composition, assessed using the Maltron BioScan 920-II to analyze bioimpedance; and dietary intake, assessed with three-day dietary records. Among the neonatal factors, birth weight and length, number of daily feedings and type of delivery were included. The composition of HM, including energy content, protein, fat and carbohydrate concentrations, was analyzed using the Miris human milk analyzer. Pearson's and Spearman's correlation coefficients and multivariable logistic regression models were used to analyze the association between the selected maternal and infant factors and HM milk composition. It was found that total protein content of HM was correlated with pre-pregnancy BMI (Spearman rho = 0.238; p = 0.037), current lean body mass (Spearman rho = -0.293, p = 0.01) and total water content (Spearman rho = -0.315, p = 0.005). Carbohydrates were the only macronutrients whose composition was significantly affected by the infant factors. It was reported that higher carbohydrate content was associated with male sex (OR = 4.52, p = 0.049). Our results show that maternal and infant factors, especially maternal pre-pregnancy and current nutritional status and infant sex, interact and affect HM composition, suggesting that macronutrient and energy content in HM may be determined in pregnancy and may have unique compositional profile for every mother-infant dyad.

Components of human breast milk: from macronutrient to microbiome and microRNA

Human breast milk (HBM) is essential for the infant's growth and development right after birth and is an irreplaceable source of nutrition for early human survival. Various infant formulas have many similarities to HBM in many components, but there is no perfect substitute for HBM. Recently, various breast milk components and their roles have been studied according to the development of various analysis techniques. As is already well known, HBM contains about 87%-88% water, and 124- g/L solid components as macronutrients, including about 7% (60-70 g/L) carbohydrates, 1% (8-10 g/L) protein, and 3.8% (35-40 g/L) fat. The composition may vary depending on the environmental factors, including maternal diet. Colostrum is low in fat but high in protein and relatively rich in immuneprotective components. Although HBM contains enough vitamins to ensure normal growth of the infant, vitamins D and K may be insufficient, and the infant may require their supplementation. Growth factors in HBM also serve as various bioactive proteins and peptides on the intestinal tract, vasculature, nervous system, and endocrine system. In the past, HBM of a healthy mother was thought to be sterile. However, several subsequent studies have confirmed the presence of rich and diverse microbial communities in HBM. Some studies suggested that the genera Staphylococcus and Streptococcus may be universally predominant in HBM, but the origin of microbiota still remains controversial. Lastly, milk is the one of most abundant body fluid of microRNAs, which are known to play a role in various functions, such as immunoprotection and developmental programming, through delivering from HBM and absorption by intestinal epithelial cells. In conclusion, HBM is the most important source of nutrition for infants and includes microbiomes and miRNAs for growth, development, and immunity.

Factors Influencing the Duration of Breastfeeding among Polish Women

Objective

The study aimed to analyse the factors that influence the duration of breastfeeding among Polish women.

Materials and methods

The study group consisted of 1,024 mothers of children aged 6–18 months who were breastfeeding or are currently breastfeeding. Data were collected through a computer-assisted Web interview. Univariate analysis and correspondence analysis were performed to determine the predictors of exclusive breast-feeding and breastfeeding among Polish women.

Results

Maternal age, maternal education, pre-pregnancy body mass index, voivodeship, birth weight and due time had a significant impact on breastfeeding duration (p < 0.05). Mothers who were older (35± years of age), had a higher level of education and lived in mid-sized cities were more often breastfeeding exclusively, in accordance with the World Health Organization's recommendations. Women who were younger, had a lower level of education, lived in rural areas, and had a lower BMI breastfed exclusively for a shorter period. The most frequently suggested reason for breastfeeding cessation was maternal concerns about insufficient milk supply (41%). The percentage of women who gave up breastfeeding before the 6th month following the delivery was the highest in the northeastern region of Poland (53%), whereas the percentage of women who stopped exclusive breastfeeding was the highest in the southwest region of Poland (69.4%).

Conclusions

Our study highlights that the reasons for breastfeeding cessation are often complex. Therefore, the promotion of breastfeeding for the first 6 months of life should be a social responsibility.