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

Milk feeding and first complementary foods during the first year of life in the TEDDY study

The aim was to describe milk feeding patterns and first weaning foods during the first year of life in a large prospective birth cohort of infants with increased genetic risk for Type 1 diabetes (T1D) recruited in 4 different countries: the United States, Finland, Germany, and Sweden. All enrolled children with dietary information (n = 8,673) were included in the analyses; 1,307 (15%) children who dropped out before the first birthday were excluded from some analyses. Supplementary milk feeding in the first 3 days of life was common in all the four countries, although the type of the supplementary milk differed by country and by maternal T1D. Donated human milk was commonly used only in Finland. In all the countries, the most common first supplementary food was cow's milk-based infant formula, especially among offspring of mothers with T1D. The use of specific types of infant formulas differed notably by country: Extensively hydrolysed formulas were most used in Finland, partially hydrolysed ones in the United States and in Germany, and soy formulas only in the United States. Infant formulas commonly included probiotics, prebiotics, and starches. During the first year of life, most of the infants received conventional cow's milk. Overall, milk feeding during the first 3 days of life and thereafter until the first birthday differed markedly by maternal T1D status and across countries. These descriptive data may be useful in understanding early infant feeding practices and in planning potential interventions, which affect infant feeding.

Human Milk Oligosaccharides: 2'-Fucosyllactose (2'-FL) and Lacto-N-Neotetraose (LNnT) in Infant Formula

The authors reviewed the published evidence on the presence of oligosaccharides in human milk (HMO) and their benefits in in vitro and in vivo studies. The still limited data of trials evaluating the effect of mainly 2′-fucosyllactose (2′-FL) on the addition of some of HMOs to infant formula were also reviewed. PubMed was searched from January 1990 to April 2018. The amount of HMOs in mother’s milk is a dynamic process as it changes over time. Many factors, such as duration of lactation, environmental, and genetic factors, influence the amount of HMOs. HMOs may support immune function development and provide protection against infectious diseases directly through the interaction of the gut epithelial cells or indirectly through the modulation of the gut microbiota, including the stimulation of the bifidobacteria. The limited clinical data suggest that the addition of HMOs to infant formula seems to be safe and well tolerated, inducing a normal growth and suggesting a trend towards health benefits. HMOs are one of the major differences between cow’s milk and human milk, and available evidence indicates that these components do have a health promoting benefit. The addition of one or two of these components to infant formula is safe, and brings infant formula closer to human milk. More prospective, randomized trials in infants are need to evaluate the clinical benefit of supplementing infant formula with HMOs.

Are cortisol concentrations in human breast milk associated with infant crying?

The present longitudinal study is the first to investigate the association between human breast milk cortisol and infant crying over the first three months of life. Higher concentrations of breast milk cortisol were expected to be differentially associated with fussing and crying in boys and girls. At 2, 6, and 12 weeks of infant age, mothers (N = 70) collected a morning sample of their milk and kept a 3‐day diary to measure infant fussing and crying. Cortisol was extracted and quantified from milk samples. Results showed that breast milk cortisol concentrations increased from 2 weeks through 12 weeks of infant age. Milk cortisol was unrelated to the total duration, frequency, and bout length of infant fussing and crying for both boys and girls. Directions for future research aiming to extend our knowledge on the biology of milk cortisol in relation to infant behavior and development are discussed.

Timing of complementary feeding and associations with maternal and infant characteristics: A Norwegian cross-sectional study

Norwegian Health authorities recommend solid food to be introduced between child age 4-6 months, depending on both the mother´s and infant's needs. The aim of this paper is to describe timing of complementary feeding in a current sample of Norwegian mother/infant-dyads and explore potential associations between timing of introduction to solid foods and a wide range of maternal and infant characteristics known from previous literature to influence early feeding interactions. The paper is based on data from the Norwegian randomized controlled trial Early Food for Future Health. In 2016, a total of 715 mothers completed a web-based questionnaire at child age 5.5 months. We found that 5% of the infants were introduced to solid food before 4 months of age, while 14% were not introduced to solid food at 5.5 months of age. Introduction of solid food before 4 months of age was associated with the infant not being exclusive breastfed the first month, receiving only formula milk at 3 months, the mother being younger, not married/cohabitant, smoking, less educated and having more economic difficulties. Not being introduced to solid food at 5.5 months was associated with the infant being a girl, being exclusive breastfed the first month, receiving only breastmilk at 3 months, the mother being older, married and having 3 or more children. This study shows that there are still clear socioeconomic differences regarding timing of complementary feeding in Norway. Infants of younger, less educated and smoking mothers are at higher risk of not being fed in compliance with the official infant feeding recommendations. Our findings emphasize the importance of targeting socioeconomically disadvantaged mothers for support on healthy feeding practices focusing on the infant`s needs to prevent early onset of social inequalities in health.

The impact of human breast milk components on the infant metabolism

BACKGROUND & AIMS

Breastfeeding is beneficial for mothers and infants. Underlying mechanisms and biochemical mediators thus need to be investigated to develop and support improved infant nutrition practices promoting the child health. We analysed the relation between maternal breast milk composition and infant metabolism.

METHODS

196 pairs of mothers and infants from a European research project (PreventCD) were studied. Maternal milk samples collected at month 1 and month 4 after birth were analysed for macronutrient classes, hormone, and fatty acid (FA) content. Phospholipids, acylcarnitines, and amino acids were measured in serum samples of 4-month old infants. Associations between milk components and infant metabolites were analysed with spearman correlation and linear mixed effect models (LME). P-values were corrected for multiple testing (PLME).

RESULTS

Month 1 milk protein content was strongly associated with infant serum lyso-phosphatidylcholine (LPC) 14:0 (PLME = 0.009). Month 1 milk insulin was associated to infant acetylcarnitine (PLME = 0.01). There were no associations between milk protein content and serum amino acids and milk total fat content and serum polar lipids. Middle- and odd-chain FA% in breast milk at both ages were significantly related to serum LPC and sphingomyelins (SM) species in infant serum (all PLME<0.05), while FA% 20:5n-3 and 22:6n-3 percentages were significantly associated to serum LPC 22:6 (PLME = 1.91×10-4/7.93×10-5) in milk only at month 4. Other polyunsaturated fatty acids and hormones in milk showed only weak associations with infant serum metabolites.

CONCLUSIONS

Infant serum LPC are influenced by breast milk FA composition and, intriguingly, milk protein content in early but not late lactation. LPC 14:0, previously found positively associated with obesity risk, was the serum metabolite which was the most strongly associated to milk protein content. Thus, LPC 14:0 might be a key metabolite not only reflecting milk protein intake in infants, but also relating high protein content in milk or infant formula to childhood obesity risk.

Oleuropein and hydroxytyrosol protect rats' pups against bisphenol A induced hypothyroidism

Bisphenol A (BPA) can disturb the endocrine system and the organs that respond to endocrine signals in organisms, indirectly exposed during prenatal and/or early postnatal life. The present study was designed to assess the protective effect of phenolic compounds from olive leaves against BPA induced thyroid dysfunction and growth perturbation in young rats during lactation. The BPA disrupting effect on thyroid function was investigated by measuring changes in plasma levels of thyroid hormones. Free triiodothyronine (FT3) and thyroxine (FT4) were decreased in young rats breast-fed from mothers treated with bisphenol A. This effect was associated with an increase in the plasma level of thyroid-stimulating hormone (TSH). The histological and immunohistochemical study of the thyroid gland revealed a disturbance in morphological structure and thyroid cells function. Thyroid dysfunction led to a disruption in the skeletal bone growth of young rats. In fact, the infrared microspectroscopic analysis and histological examination of femoral bone showed significant changes in their histoarchitecture associated with a perturbation in the mechanism of bone tissue mineralization. The administration of oleuropein or hydroxytyrosol in BPA treated lactating mothers improved the thyroid cells function by enhancing thyroid hormone levels. Moreover, these phenolics increased the body growth characterized by an amelioration in the structure and the microstructure of femoral bone tissue. HPLC analysis of rats-breast milk indicated the presence of oleuropein and hydroxytyrosol, which could contribute to the protective effect against bisphenol A induced hypothyroidism in pups rats.

Examining the relationship between socioeconomic status and the double burden of maternal over and child under-nutrition in Bangladesh

BACKGROUND/OBJECTIVES

There is little research on the association between socioeconomic status (SES) and the familial co-existence of maternal over and child under-nutrition (MOCU). Most of these studies conducted in the Latin American countries. Therefore, we intended to further this important area of query by exploring the relationship between SES and the dual burden of MOCU in Bangladesh.

SUBJECTS/METHODS

We used data from the 2014 Bangladesh Demographic Health Survey (BDHS). The analyses were based on the responses of 5687 mother-child pairs. We focused standard of living (hereafter referred to as wealth) as a measure of SES. We determined MOCU if there were an undernourished child and an overweight mother in the same household.

RESULTS

Maternal overweight and MOCU prevalence is higher among the wealthier segment whereas prevalence of child under-nutrition is higher among the poorest segment of the households. The relative risk of a household having MOCU increased by the factors of 2.84 (confidence interval (CI) = 1.58-5.12) among households with richest bands of wealth compared to the poorest category. Household from the medium (Relative risk ratio (RRR) = 1.87, 95% CI = 1.07-3.28) and richer SES groups (RRR = 2.56, 95% CI = 1.39-4.69) had increased chance for MOCU as compared to the household from poorest SES group.

CONCLUSIONS

As opposed to findings from other Latin American countries, the prevalence of MOCU in Bangladesh is higher in the wealthiest households. Findings of our study therefore suggest that overweight prevention programs in wealthier households of Bangladesh need to think out the possibility that their focus households may also include underweight persons.

Human milk peptides differentiate between the preterm and term infant and across varying lactational stages

Variations in endogenous peptide profiles, functionality, and the enzymes responsible for the formation of these peptides in human milk are understudied. Additionally, there is a lack of knowledge regarding peptides in donor human milk, which is used to feed preterm infants when mother's own milk is not (sufficiently) available. To assess this, 29 human milk samples from the Dutch Human Milk Bank were analyzed as three groups, preterm late lactation stage (LS) (n = 12), term early (n = 8) and term late LS (n = 9). Gestational age (GA) groups were defined as preterm (24-36 weeks) and term (≥37 weeks). LS was determined as days postpartum as early (16-36 days) or late (55-88 days). Peptides, analyzed by LC-MS/MS, and parent proteins (proteins from matched peptide sequences) were identified and quantified, after which peptide functionality and the enzymes responsible for protein cleavage were determined. A total of 16 different parent proteins were identified from human milk, with no differences by GA or LS. We identified 1104 endogenous peptides, of which, the majority were from the parent proteins β-casein, polymeric immunoglobulin receptor, α_s1-casein, osteopontin, and κ-casein. The absolute number of peptides differed by GA and LS with 30 and 41 differing sequences respectively (p < 0.05) Odds likelihood tests determined that 32 peptides had a predicted bioactive functionality, with no significant differences between groups. Enzyme prediction analysis showed that plasmin/trypsin enzymes most likely cleaved the identified human milk peptides. These results explain some of the variation in endogenous peptides in human milk, leading to future targets that may be studied for functionality.

Holder-Pasteurized Human Donor Milk: How Long Can It Be Preserved?

OBJECTIVE

When own mother's milk falls short, pasteurized human donor milk is recommended as alternative feeding for preterm infants. Donor milk has to meet the highest safety standards, but its processing and storage is expensive. The recommended storage time of pasteurized donor milk is 3 months. The objective of the present study was to determine whether the frozen storage time of pasteurized donor milk can be extended beyond 3 months without compromising its safety and quality.

METHODS

For this prospective observational study breast milk samples of 34 unique women, collected between November 2014 and June 2015, were provided by the Dutch Human Milk Bank. Samples were Holder pasteurized within 3 months after expression and stored at -20°C. Analysis of both bacterial growth (by inoculation of milk on a blood and a cysteine-, lactose-, and electrolyte-deficient agar) and fat, crude protein, carbohydrate and energy content of milk (analyzed by infrared spectroscopy) was done monthly during the first 6 months and every 2 months thereafter, up to 1 year postpasteurization.

RESULTS

Thirty of 306 (9.8%) follow-up samples showed bacterial growth when cultured. None of the samples showed sequential contamination with the same strain up to 8 months of frozen storage. No significant decreases in macronutrients and energy content were observed over 8 months.

CONCLUSION

Pasteurized human donor milk can be stored safely for 8 months at -20°C, without compromising its macronutrient and energy content. This longer storage time will reduce disposal of expired donor milk and subsequently reduce costs.

Reasons for non-exclusive breast-feeding in the first 6 months

BACKGROUND

Maternal sociodemographic, delivery- and infant-related factors as well as hospital practice are relevant for breast-feeding practice. The aim of this study was to identify the sociodemographic and delivery-related factors that may affect exclusive breast-feeding (EBF) of infants aged 0-6 months in Poland.

METHODS

A total of 446 mothers (18-42 years old) of infants aged 0-6 months were interviewed using the computer-assisted Web interview method. The questionnaire collected information about maternal sociodemographic situation and anthropometrics, delivery-related factors, and infant feeding-related factors. Data were analyzed using the chi-squared test and Mann-Whitney U-test. Predictors of non-exclusive breast-feeding (N-EBF) in the first 6 months of life were assessed on multivariate logistic regression.

RESULTS

A total of 43% of mothers did not breast-feed exclusively (n = 191; N-EBF group) and 57% did breast-feed exclusively during the study period (n = 255; EBF group). After adjustment for other potential risk factors, the highest risk factors for N-EBF were maternal age <20 years (OR, 6.12; P ≤ 0.01), and inadequate breast-feeding knowledge (OR, 3.43; P ≤ 0.01), whereas the lowest risk was associated with pre-pregnancy intention to breast-feed (OR, 0.35; P ≤ 0.01), very good knowledge about breast-feeding (OR, 0.45; P ≤ 0.001) and maternal age 26-30 years (OR, 0.48; P ≤ 0.001). In a multivariate model, maternal education, employment status and preterm delivery were no longer statistically significant.

CONCLUSIONS

Breast-feeding practice is influenced by a variety of factors, including sociodemographic and psychosocial conditions, maternal obesity and mode of delivery. Further work is needed to establish the role of education and prophylactic programs in modifying the aforementioned risk factors.

Low Transfer of Tacrolimus and Its Metabolites into Colostrum of Graft Recipient Mothers

Currently, the majority of neonates born to organ recipient mothers on chronic immunosuppressive therapy are formula fed. However, over the past few years, evidence has grown, suggesting that breastfeeding might be possible and beneficial. We designed a study assessing the transfer of tacrolimus into the colostrum of posttransplant mothers. We assessed the amount of tacrolimus and its metabolites, M-1 and M-3, that would be ingested by the breastfed neonates. Concentrations of tacrolimus and its metabolites were measured in colostrum from 14 posttransplant mothers as well as in venous cord blood and venous blood of the neonates. Test material analysis was performed by liquid chromatography coupled with mass spectrometry (LC/MS). The amount of ingested formula was registered, which allowed for estimation of the amount of tacrolimus and its metabolites that would be ingested by breastfed infants. The mean amount of tacrolimus that would be ingested by the neonates in maternal milk was 151.4 ng/kg/24 h (standard deviation SD ± 74.39); metabolite M-1: 23.80 ng/kg/24 h (SD ± 14.53); and metabolite M-3: 13.25 ng/kg/24 h (SD ± 9.05). The peak level of tacrolimus and metabolite M-1 in colostrum was noted 8 h after an oral dose (3.219 ng/mL SD ± 2.22 and 0.56 ng/mL SD ± 0.60, respectively) and metabolite M-3 after 6 h (0.29 ng/mL SD ± 0.22). Low concentrations of tacrolimus and its metabolites, M-1 and M-3, in colostrum show that neonates will ingest trace amounts of the drug. Further studies are required to fully assess the safety of breastfeeding by posttransplant mothers.

Importance of maternal diet in the training of the infant's immune system during gestation and lactation

Latest forecasts predict that half of the European population will be allergic within the coming 15 years, with food allergies contributing substantially to the total burden; preventive measures are urgently needed. Unfortunately, all attempted alimentary strategies for primary prevention of allergic diseases through allergen avoidance so far have failed. This also holds true for the prevention of food allergies in breastfed infants by the common practice of excluding certain foods with allergenic potential from the maternal diet. As a preventive measure, therefore, exclusion diets should be discouraged. They can exhaust nursing mothers and negatively impact both their nutritional status as well as their motivation to breastfeed. A prolonged exclusion diet may be indicated solely in cases of doctor-diagnosed food allergy following rigid medical tests (e.g. double-blind placebo-controlled food challenges). Indicated cases usually involve exclusion of only a few food items. Continued breastfeeding is generally important for many aspects of the infant's health, including the training of the infant's immune responses to foreign compounds and avoidance of overshooting inflammatory responses. Recent studies suggest that the presence of maternal dietary proteins in amniotic fluid, cord blood, and human milk might support the induction of tolerance towards solid foods in infants. These are exactly the same species of proteins or remnants thereof that, in comparatively few cases, trigger allergic responses. However, the insight that the proteins of maternal dietary origin in human milk are more likely to be cure (or, more precise, directing prevention) than curse has still largely evaded the attention of health care professionals consulted by worried breastfeeding mothers. In this paper, we summarize recent literature on the importance of exposure to dietary proteins in the establishment of immunological tolerance and hence prevention of allergic disease. Multiple organizations have used the scientific knowledge to build (local) guidelines (e.g. AAAAI, EAACI, BSACI) that can support health care professionals to provide the best strategy to prevent the onset of allergic diseases. We thus hope to clarify existing confusion about the allergenic propensities of dietary proteins during early life, which has contributed to exaggerated fears around the diet of pregnant and breastfeeding mothers.

Adipokines in human breast milk

The review describes the molecular characteristics of so far detected breast milk adipokines and ranks their breast milk level compared to the respective levels in maternal and infant blood. Moreover, analytical knowledge for measurements of breast milk adipokines will be delineated. Next, we summarized data about two main potential influencing factors on adipokine concentration in breast milk, maternal weight and pasteurization of milk. Finally, associations between adipokines in breast milk and weight gain in infants as well as the putative mechanisms for effects of breast milk adipokines on food intake and weight gain in later life will debated. Our findings suggest that a source of adipokines in human breast milk cannot be uniformly defined. In dependence on the ratio between serum and breast milk levels the major quantity of these proteins may be derived from peripheral tissues, from the breast tissue itself or from both. Thus, leptin and in part adiponectin levels in breast milk are dependent on a plenty of influencing factors with an important relevance of maternal anthropometric characteristics There is some evidence that leptin, adiponectin and ghrelin levels in breast milk may be associated with growth gain of infants and even with increased risk for being overweight during infancy or childhood. We hypothesize that a dysregulation in adipokine homeostasis in early life could promote obesity and metabolic disturbance in later life.

DHA and ARA addition to infant formula: Current status and future research directions

Docosahexaenoic acid (DHA) and arachidonic acid (ARA) are present in breast milk and play important roles in early infant development. A supply of these fatty acids in infant formula (typically following breast milk as a model with ARA > DHA) is thought to be important since endogenous synthesis is insufficient to maintain tissue levels equivalent to breast-fed infants. Intervention studies assessing the impact of DHA- and ARA-supplemented formulas have resulted in numerous positive developmental outcomes (closer to breast-fed infants) including measures of specific cognition functions, visual acuity, and immune responses. A critical analysis of outcome assessment tools reveals the essentiality of selecting appropriate, focused techniques in order to provide accurate evaluation of DHA- and ARA-supplemented formulas. Future research directions should encompass in-depth assessment of specific cognitive outcomes, immune function, and disease incidence, as well as sources of experimental variability such as the status of fatty acid desaturase polymorphisms.

Use of infant formula in the ELFE study: The association with social and health-related factors

Breastfeeding is recommended until 6 months of age, but a wide range of infant formula is available for nonbreastfed or partially breastfed infants. Our aim was to describe infant formula selection and to examine social- and health-related factors associated with this selection. Analyses were based on 13,291 infants from the French national birth cohort Etude Longitudinale Française depuis l'Enfance. Infant diet was assessed at Month 2 by phone interview and monthly from Months 3 to 10 via internet/paper questionnaires. Infant formulas were categorized in 6 groups: extensively or partially hydrolysed, regular with or without prebiotics/probiotics, and thickened with or without prebiotics/probiotics. Associations between type of infant formula used at 2 months and family or infant characteristics were assessed by multinomial logistic regressions. At Month 2, 58.1% of formula-fed infants were fed with formula enriched in prebiotics/probiotics, 31.5% with thickened formula, and 1.4% with extensively hydrolysed formula. The proportion of formula-fed infants increased regularly, but the type of infant formula used was fairly stable between 2 and 10 months. At Month 2, extensively hydrolysed formulas were more likely to be used in infants with diarrhoea or regurgitation problems. Partially hydrolysed formulas were more often used in families with high income, with a history of allergy, or with infants with regurgitation issues. Thickened formulas were used more with boys, preterm infants, infants with regurgitation issues, or in cases of early maternal return to work. The main factors related to the selection of infant formula were family and infant health-related ones.

Sterols in human milk during lactation: bioaccessibility and estimated intakes

Total sterol content decreased to the half throughout lactation, being their intake lower at colostrum and its bioaccessibility higher at first month.

Clinician performed ultrasound in fetal growth restriction: fetal, neonatal and pediatric aspects

Fetal growth restriction (FGR) affects 7-10% pregnancies. Conventional and tissue Doppler imaging has noted cardiac compromise during fetal and early neonatal periods in this cohort. In this article, we discuss the use of salient ultrasound parameters across age groups. During fetal life, certain feto-placental sonographic parameters have been linked to adverse perinatal outcomes and are predictive of later life hypertension. During the early postnatal period altered morphometry (hypertrophied and globular hearts) with sub-clinical impairment of cardiac function has been noted in both term and preterm infants with FGR. Vascular imaging has noted thickened and stiffer arteries in association with significantly elevated blood pressure. Similar findings in the pediatric age groups indicate persistence of these alterations, and have formed the basis of intervention studies. Assessment methodology and clinical relevance of these parameters, especially in designing and monitoring of intervention strategies is discussed. Frontline care givers (obstetricians and neonatologists) are increasingly using point of care ultrasound to discern these manifestations of FGR during the sub-clinical phase.

Promotion of breastfeeding in Poland: the current situation

Objective

Exclusive breastfeeding is safe and beneficial for healthy infants; it is the optimal feeding method during the first 6 months of life. Infants should be complementary fed in conjunction with breastfeeding until 12 months of age or longer. The aim of the present study was to analyse the duration of breastfeeding through 12 months of age.

Methods

Participants were 1679 women from 42 randomly selected hospitals in Poland. The data were obtained from surveys, including a paper and pencil interview that was conducted after mothers delivered in the hospital and before discharge. Computer aided telephone interviews were administered at 2, 4, 6 and 12 months.

Results

There was a high rate of initiating breastfeeding after birth (97%), a rapid abandonment of exclusive breastfeeding (43.5% at 2 months, 28.9% at 4 months and 4% at 6 months) and an onset of formula feeding during the first days of life, which is contrary to current recommendations.

Conclusions

It is necessary re-educate mothers, medical staff who care for mothers and children during the perinatal period, and other specialists.

Fetal and preterm infant microbiomes: a new perspective of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a devastating condition of hospitalized preterm infants. Numerous studies have attempted to identify the cause of NEC by examining the immunological features associated with pathogenic microorganisms. No single organism has proven responsible for the disease; however, immunological studies are now focused on the microbiome. Recent research has investigated the numerous bacterial species residing in the body and their role in diseases in preterm infants. The timing of initial microbial colonization is a subject of interest. The microbiome appears to transfer from the mother to the newborn, as well as to the fetus. Cross-talk between the fetus and fetal microbiome takes place continuously to generate a unique immune system. This review examined the transfer of the microbiome to the human fetus, and its potential relationship with NEC.

Benefits of Lactoferrin, Osteopontin and Milk Fat Globule Membranes for Infants

The provision of essential and non-essential amino acids for breast-fed infants is the major function of milk proteins. In addition, breast-fed infants might benefit from bioactivities of milk proteins, which are exhibited in the intestine during the digestive phase and by absorption of intact proteins or derived peptides. For lactoferrin, osteopontin and milk fat globule membrane proteins/lipids, which have not until recently been included in substantial amounts in infant formulas, in vitro experiments and animal models provide a convincing base of evidence for bioactivities, which contribute to the protection of the infant from pathogens, improve nutrient absorption, support the development of the immune system and provide components for optimal neurodevelopment. Technologies have become available to obtain these compounds from cow´s milk and the bovine compounds also exhibit bioactivities in humans. Randomized clinical trials with experimental infant formulas incorporating lactoferrin, osteopontin, or milk fat globule membranes have already provided some evidence for clinical benefits. This review aims to compare findings from laboratory and animal experiments with outcomes of clinical studies. There is good justification from basic science and there are promising results from clinical studies for beneficial effects of lactoferrin, osteopontin and the milk fat globule membrane complex of proteins and lipids. Further studies should ideally be adequately powered to investigate effects on clinically relevant endpoints in healthy term infants.

Excessive weight gain in exclusively breast-fed infants

BACKGROUND

Breastfeeding is recommended as the best source of nutrition in the first months of life and observational studies have associated exclusive breastfeeding with decreased weight gain and a protective effect against obesity in childhood. The objective of this study was to describe the characteristics of a cohort of exclusively breastfed obese infants to determine factors that may lead to this unusual weight gain.

METHODS

Infants seen between 2003 and 2015 who were exclusively breastfed and showed excessive weight gain in the first year of life were followed with a focus on features of the mother, the child, feeding patterns and the presence of concomitant factors that influence nutritional status. Additionally, in a subset of the sample, macronutrients of the maternal breast milk were analyzed. A descriptive, prospective cross-sectional study was conducted.

RESULTS

Of 73 patients, 63% were girls. At 3 months of life, 64% had a weight-for-height standard deviation score (SDS) >2. At 6 and at 12 months, 100% of the patients had a weight-for-height >2 SDS. The mean age at semisolid-food introduction was 7 months. The mean age at weaning was 15.8 months. The babies were fed on demand and no hunger-satiety pattern was observed. In the breast milk samples analyzed, a significantly lower fat content was found.

CONCLUSIONS

The results of our study lead to the assumption that inter-individual variations in mother's milk composition may affect the growth patterns of children.

Beta Palmitate Improves Bone Length and Quality during Catch-Up Growth in Young Rats

Palmitic acid (PA) is the most abundant saturated fatty acid in human milk, where it is heavily concentrated in the sn-2-position (termed beta palmitate, BPA) and as such is conserved in all women, regardless of their diet or ethnicity, indicating its physiological and metabolic importance. We hypothesized that BPA improves the efficiency of nutrition-induced catch up growth as compared to sn-1,3 PA, which is present in vegetable oil. Pre-pubertal male rats were subjected to a 17 days food restriction followed by re-feeding for nine days with 1,3 PA or BPA-containing diets. We measured bone length, epiphyseal growth plate height (EGP, histology), bone quality (micro-CT and 3-point bending assay), and gene expression (Affymetrix). The BPA-containing diet improved most growth parameters: humeri length and EGP height were greater in the BPA-fed animals. Further analysis of the EGP revealed that the hypertrophic zone was significantly higher in the BPA group. In addition, Affymetrix analysis revealed that the diet affected the expression of several genes in the liver and EGP. Despite the very subtle difference between the diets and the short re-feeding period, we found a small but significant improvement in most growth parameters in the BPA-fed rats. This pre-clinical study may have important implications, especially for children with growth disorders and children with special nutritional needs.

Randomised controlled trial demonstrates that fermented infant formula with short-chain galacto-oligosaccharides and long-chain fructo-oligosaccharides reduces the incidence of infantile colic

AIM

We examined the effects on gastrointestinal (GI) tolerance of a novel infant formula that combined specific fermented formula (FERM) with short-chain galacto-oligosaccharides and long-chain fructo-oligosaccharides (scGOS/lcFOS), with a 9:1 ratio and concentration of 0.8 g/100 mL.

METHODS

This prospective, double-blind, randomised, controlled trial comprised 432 healthy, term infants aged 0-28 days whose parents decided to not start, or discontinued, breastfeeding. Infant formula with scGOS/lcFOS+50%FERM, scGOS/lcFOS+15%FERM, 50%FERM and scGOS/lcFOS were tested. Parents completed standardised seven-day diaries on GI symptoms, crying, sleeping and stool characteristics each month until the infants were 17 weeks.

RESULTS

All the formulas were well tolerated. At four weeks, the overall incidence of infantile colic was significantly lower (8%) with scGOS/lcFOS+50%FERM than scGOS/lcFOS (20%, p = 0.034) or 50%FERM (20%, p = 0.036). Longitudinal modelling showed that scGOS/lcFOS+50%FERM-fed infants also displayed a persistently lower daily crying duration and showed a consistent stool-softening effect than infants who received formula without scGOS/lcFOS.

CONCLUSION

The combination of fermented formula with scGOS/lcFOS was well tolerated and showed a lower overall crying time, a lower incidence of infantile colic and a stool-softening effect in healthy term infants. These findings suggest for the first time that a specific infant formula has a preventive effect on infantile colic in formula-fed infants.

Effects of osteopontin-enriched formula on lymphocyte subsets in the first 6 months of life: a randomized controlled trial

BackgroundHuman milk is rich in osteopontin (OPN), which has immunomodulatory functions.MethodsIn a randomized controlled trial, standard formula (SF) and the same formula with 65 mg of OPN/L (F65) or 130 mg of OPN/L (F130), representing ~50 and 100% of the OPN concentration in human milk, were compared. We examined frequencies and composition of peripheral blood immune cells by four-color immunoflow cytometry of formula-fed infants at ages 1, 4, and 6 months, and compared them with a breastfed (BF) reference group.ResultsThe F130 group had increased T-cell proportions compared with the SF (P=0.036, average effect size 0.51) and F65 groups (P=0.008, average effect size 0.65). Compared with the BF group, the monocyte proportions were increased in the F65 (P=0.001, average effect size 0.59) and F130 (P=0.006, average effect size 0.50) groups, but were comparable among the formula groups.ConclusionOPN in an infant formula at a concentration close to that of human milk increased the proportion of circulating T cells compared with both SF and formula with added OPN at ~50% of the concentration in human milk. This suggests that OPN may favorably influence immune ontogeny in infancy and that the effects appear to be dose-dependent.

Infant feeding practices in a South African birth cohort-A longitudinal study

Childhood malnutrition is highly prevalent in low- and middle-income countries. The choices of complementary foods, which are important in infant nutrition, are poorly described in this setting. We investigated infant feeding practices in a South African birth cohort, the Drakenstein Child Health Study. Longitudinal feeding data were collected from March 2012 to March 2015. Feeding practices at birth, 6-10 and 14 weeks and 6, 9, and 12 months, were investigated using food frequency questionnaires. Anthropometry was measured at birth and 12 months. The quality of the diet was analyzed using the World Health Organization infant and young child feeding indicators. Regression models were used to explore associations between feeding and growth outcomes at 1 year. Exclusive breastfeeding for 6 months was low (13%), and 19% of infants were introduced to solid foods before 4 months. There was high daily consumption of processed meat (56%) and inappropriate foods such as fruit juice (82%), soft drinks (54%), and refined sugary foods (51%) at 1 year. Dietary diversity and consumption of iron rich foods were low at 6 months (5% and 3%, respectively) but higher by 12 months (75% and 78%). Longer duration of exclusive breastfeeding was associated with a lower height-for-age z-score at 1 year. Several dietary deficits and a rising trend in the consumption of inappropriate nutritionally poor foods were identified. These findings raise concern about poor dietary practices and the impact on child and long-term health.

Adolescents' Knowledge of Breastfeeding and Their Intention to Breastfeed in the Future

The aim of this paper is to analyze third-year secondary school students’ knowledge of breastfeeding and intention to breastfeed their children, based on the results of a questionnaire. The respondents were 154 students (101 female/43 male) of two secondary schools in Bjelovar. The students completed a questionnaire which consisted of 23 questions regarding knowledge and intention to breastfeed. The answers were analyzed statistically and different results were compared by nonparametric tests. About half of the respondents think that both partners should decide on breastfeeding and recognize the role that fathers have in initiating and maintaining breastfeeding. Only 13.64% of the respondents know that breastfeeding is to be done only on demand. Exclusive breastfeeding for 6 months, as recommended by the medical profession, is recognized by 70.13% of the students. The question on how justified is the initiation of formula together with the mother’s milk was answered correctly by 29.22% of the students. Secondary school students’ knowledge of breastfeeding is insufficient, and schools, families, social communities and other sources of information should share the responsibility for improving this. We consider it necessary to pay more attention to improving students’ knowledge of breastfeeding through school curricula.

An Australian Consensus on Infant Feeding Guidelines to Prevent Food Allergy: Outcomes From the Australian Infant Feeding Summit

BACKGROUND

Infant feeding in the first postnatal year of life has an important role in an infant's risk of developing food allergy. Consumer infant feeding advice is diverse and lacks consistency.

AIM

The Australian Infant Feeding Summit was held with the aim of achieving national consensus on the wording of guidelines for infant feeding and allergy prevention.

METHODS

Two meetings were hosted by the Centre for Food and Allergy Research, the Australasian Society of Clinical Immunology and Allergy, and the Australian National Allergy Strategy. The first meeting of 30 allergy researchers, clinicians, and consumers assessed the evidence. The second consensus meeting involved 46 expert stakeholders including state and federal health care agencies, consumers, and experts in allergy, infant feeding, and population health.

RESULTS

Partner stakeholders agreed on consensus wording for infant feeding advice: CONCLUSIONS: Consensus was achieved in a context in which there is a high prevalence of food allergy. Guidelines for other countries are being updated. Provision of consistent wording related to infant feeding to reduce food allergy risk will ensure clear consumer advice.

Physician practice in food allergy prevention in the Middle East and North Africa

BACKGROUND

A number of scientific organisations have developed guidelines for the primary prevention of allergic disease through nutritional interventions. However, even if the best evidence-based guidelines are available, these guidelines do not necessarily lead to adherence and improved health outcomes.

METHOD

To determine how closely the practice of physicians in select Middle Eastern and North African countries compares with the current recommendations on the primary prevention of allergy a survey study was performed using a structured questionnaire and convenience sampling.

RESULTS

A total of 1481 physicians responded, of which 66.1% were pediatricians. A total of 76.6% of responding physicians routinely identify infants who are at risk for developing allergy. In infants at risk for developing allergy, 89.1% recommend exclusive breastfeeding for at least 4 months. In contrast to current recommendations, 51.6% routinely recommend avoidance of any allergenic food in the lactating mother. In infants at risk of developing allergy who are completely formula fed, standard infant formula was recommended by 22.5% of responders. Of the responding physicians, 50.6% would recommend delaying the introduction of complementary food in infants at risk of allergy compared to those not at risk, whereas 62.5% would recommend postponing the introduction of potentially allergenic foods. Only 6.6% stated they follow all current recommendations on food allergy prevention.

CONCLUSION

The results of this survey suggest that a substantial part of responding physicians from select Middle Eastern and North African (MENA) countries do not follow current recommendations on primary prevention of allergic disease through nutritional interventions.

Purification and characterization of recombinant human bile salt-stimulated lipase expressed in milk of transgenic cloned cows

Bile salt-stimulated lipase (BSSL) is a lipolytic digestive enzyme with broad substrate specificity secreted from exocrine pancreas into the intestinal lumen in all species and from the lactating mammary gland into the milk of some species, notably humans but not cows. BSSL in breast milk facilitates digestion and absorption of milk fat and promotes growth of small for gestational age preterm infants. Thus, purified recombinant human BSSL (rhBSSL) can be used for treatment of patients with fat malabsorption and expressing rhBSSL in the milk of transgenic cloned cows would therefore be a mean to meet a medical need. In the present study, a vector pBAC-hLF-hBSSL was constructed, which efficiently expressed active rhBSSL in milk of transgenic cloned cows to a concentration of 9.8 mg/ml. The rhBSSL purified from cow milk had the same enzymatic activity, N-terminal amino acid sequence, amino acid composition and isoelectric point and similar physicochemical characteristics as human native BSSL. Our study supports the use of transgenic cattle for the cost-competitive, large-scale production of therapeutic rhBSSL.

Milk Fat Globule Membrane Supplementation in Formula Modulates the Neonatal Gut Microbiome and Normalizes Intestinal Development

Breast milk has many beneficial properties and unusual characteristics including a unique fat component, termed milk fat globule membrane (MFGM). While breast milk yields important developmental benefits, there are situations where it is unavailable resulting in a need for formula feeding. Most formulas do not contain MFGM, but derive their lipids from vegetable sources, which differ greatly in size and composition. Here we tested the effects of MFGM supplementation on intestinal development and the microbiome as well as its potential to protect against Clostridium difficile induced colitis. The pup-in-a-cup model was used to deliver either control or MFGM supplemented formula to rats from 5 to 15 days of age; with mother’s milk (MM) reared animals used as controls. While CTL formula yielded significant deficits in intestinal development as compared to MM littermates, addition of MFGM to formula restored intestinal growth, Paneth and goblet cell numbers, and tight junction protein patterns to that of MM pups. Moreover, the gut microbiota of MFGM and MM pups displayed greater similarities than CTL, and proved protective against C. difficile toxin induced inflammation. Our study thus demonstrates that addition of MFGM to formula promotes development of the intestinal epithelium and microbiome and protects against inflammation.

Nutrition of infants and young children (one to three years) and its effect on later health: A systematic review of current recommendations (EarlyNutrition project)

BACKGROUND

EarlyNutrition ( www.project-earlynutrition.eu ) is an international research project investigating the effects of early nutrition on metabolic programming.

OBJECTIVE

To summarize, by performing a systematic review, current standards, recommendations, guidelines, and regulations (hereafter, referred to as documents) on the nutrition of children up to three years of age. Special emphasis was placed on long-term effects of early nutrition, such as the risk of cardiovascular disease, hypertension, overweight, obesity, metabolic syndrome, diabetes, or glucose intolerance.

METHODS

MEDLINE, selected databases, and websites were searched for documents published between 2008 and January 2013.

RESULTS

Forty two documents met the inclusion criteria. The strongest and most consistent evidence for a protective, long-term effect was documented for breastfeeding. Also, limiting the intake of sodium and rapidly absorbed carbohydrates, use of a specific meal pattern, reducing the consumption of saturated fatty acids by replacing them with polyunsaturated fatty acids, and lowering the intake of trans fatty acids, seems beneficial. Many documents did not evaluate long-term outcomes of interest to us, or reported insufficient or imprecise data. Inconsistency in recommendations for some outcomes and research gaps were identified.

CONCLUSIONS

Our findings may serve as a helpful tool in planning further research, preventive actions against important diet-related diseases, and guidelines improvement.

Systematic Review: Early Infant Feeding and the Risk of Type 1 Diabetes

BACKGROUND

In addition to genetic background, a number of environmental factors have been claimed to influence the development of type 1 diabetes (T1D), including infant diet.

OBJECTIVE

The aim of the study was to systematically update evidence on the possible relation between early feeding practices and the risk of T1D.

METHODS

The Cochrane Library, MEDLINE, EMBASE, Web of Science, and CINAHL were searched for studies of any design up to July 2015. MEDLINE and EMBASE were additionally searched in March 2016. The primary outcome measures were the development of T1D or T1D-associated autoimmunity (T1DA).

RESULTS

Nine publications were identified. Breastfeeding at the time of gluten introduction, as compared to gluten introduction after weaning, did not reduce the risk of developing T1DA or T1D. In children at high risk of developing T1D, except for gluten introduction at 3 months or younger age compared with gluten introduction at older than 3 months, which increased the risk of T1DA, the age of gluten introduction in infants had no effect on the risk of developing T1DA.

CONCLUSIONS

Current evidence, mainly from observational studies, does not support the claim that early infant feeding practices, such as breastfeeding at gluten introduction or the age of the infant at the time of gluten introduction, may decrease the risk of developing T1D. More robust data are needed from randomized controlled trials.

Growth of Infants Fed Formula with Evolving Nutrition Composition: A Single-Arm Non-Inferiority Study

The nutritional composition of human milk evolves over the course of lactation, to match the changing needs of infants. This single-arm, non-inferiority study evaluated growth against the WHO standards in the first year of life, in infants consecutively fed four age-based formulas with compositions tailored to infants' nutritional needs during the 1st, 2nd, 3rd-6th, and 7th-12th months of age. Healthy full-term formula-fed infants (n = 32) were enrolled at ≤14 days of age and exclusively fed study formulas from enrollment, to the age of four months. Powdered study formulas were provided in single-serving capsules that were reconstituted using a dedicated automated preparation system, to ensure precise, hygienic preparation. The primary outcome was the weight-for-age z-score (WAZ) at the age of four months (vs. non-inferiority margin of -0.5 SD). Mean (95% CI) z-scores for the WAZ (0.12 (-0.15, 0.39)), as well as for the length-for-age (0.05 (-0.19, 0.30)), weight-for-length (0.16 (-0.16, 0.48)), BMI-for-age (0.11 (-0.20, 0.43)), and head circumferencefor-age (0.41 (0.16, 0.65)) at the age of four months, were non-inferior. Throughout the study, anthropometric z-scores tracked closely against the WHO standards (within ±1 SD). In sum, a fourstage, age-based infant formula system with nutritional compositions tailored to infants' evolving needs, supports healthy growth consistent with WHO standards, for the first year of life.

Breastfeeding and the risk of respiratory tract infections after infancy: The Generation R Study

Background

The protection of breastfeeding against respiratory tract infections in the first year of life has often been suggested. Few studies examined the effect of breastfeeding on respiratory tract infections after infancy.

Objective

To examine the association between breastfeeding with lower respiratory tract infections (LRTI) and upper respiratory tract infections (URTI) after infancy up to 4 years of age (n = 5322).

Methods

This study was embedded in The Generation R study, a Dutch population-based prospective cohort study from fetal life until young adulthood. Information on breastfeeding duration (never; <3 months; 3–6 months; ≥6 months) and dose (never; partially until 4 months; predominantly until 4 months) were collected by questionnaire at 2, 6, and 12 months of age. Information on doctor attendance for LRTI and URTI were obtained by questionnaire at 2, 3, and 4 years of age.

Results

Breastfeeding for 6 months or longer was significantly associated with a reduced risk of LRTI up to 4 years of age (aOR: 0.71; 95% CI: 0.51–0.98). Similar ORs for LRTI were found with breastfeeding for less than 3 months and 3–6 months. Although in the same direction, weaker ORs were found for URTI and breastfeeding duration. The same trend was found for partial and predominant breastfeeding until 4 months and LRTI and URTI.

Conclusion

Breastfeeding duration for 6 months or longer is associated with a reduced risk of LRTI in pre-school children. These findings are compatible with the hypothesis that the protective effect of breastfeeding for respiratory tract infections persist after infancy therefore supporting current recommendations for breastfeeding for at least 6 months.

Fortification of human milk for preterm infants

Human milk is the preferred feeding for all infants, including those of very low birth weight (<1500 g). It has both nutritional and anti-infective properties which are especially important for infants at risk for sepsis and necrotizing enterocolitis. When maternal milk is not available or the amount produced is not sufficient to meet daily needs, donor human milk may (should) be used in its place. However, donor human milk is generally term in quality and likely has insufficient protein to promote appropriate growth. Whether donor or mother's own milk, fortification of human milk is required to meet nutrient requirements for growth and development for these preterm infants who are at high risk for growth faltering during the hospital stay. There are multiple strategies and products that may be employed to support desired growth rates. The advent of human milk analyzers may be helpful in a more customized approach to fortification.

Relationship Between Breastfeeding and Early Childhood Obesity: Results of a Prospective Longitudinal Study from Birth to 4 Years

AIM

To study a potential link between breastfeeding in infancy and obesity at age 4.

MATERIALS AND METHODS

A total of 30,508 infants born during 2002-2007 from the databases of the Preventive Child Health Services in two Swedish counties and from national registers were studied. The outcome variable was obesity at age 4. Analyses were conducted by logistic regression models using the methodology of generalized estimating equations. Analyses were adjusted for child sex and maternal anthropometric and sociodemographic variables.

RESULTS

In unadjusted analyses, any breastfeeding up to 9 months was linked to successively decreasing odds ratios (ORs) for obesity at age 4 (ORs 0.78-0.33), however, not significantly for 1 week and 2 months of breastfeeding. In adjusted analyses, the same pattern remained statistically significant for breastfeeding for 4 (OR 0.51), 6 (OR 0.55), and 9 (OR 0.47) months. Child sex, maternal education, maternal body mass index, and maternal smoking additionally influenced child obesity.

CONCLUSION

Breastfeeding duration for at least 4 months may contribute independently to a reduced risk for childhood obesity at 4 years.

Assessment of Aflatoxin M1 and Heavy Metal Levels in Mothers Breast Milk in Famagusta, Cyprus

Breast milk contributes towards optimal nutrition for infants. However, studies showed that it can also contain different toxins and heavy metals, which reduce its health benefits. The aim of this study is to determine the level of contaminants such as aflatoxin M1 (AFM1), Pb, Cd, As, and Hg in breast milk samples from Famagusta, Cyprus. Correlations between moldy food consumption, smoking habits of the mothers, and contaminant levels in breast milk were also investigated. Breast milk samples from 50 lactating mothers in rural and urban areas of Famagusta District were analyzed for AFM1 by ELISA. Eighty percent of them were found to be contaminated with AFM1 with the mean measurement of 7.84 ± 1.72 ng/l. Socio-demographic status, moldy food consumption habits, and smoking status do not have any effect on the AFM1 levels observed in breast milk. Heavy metal levels in breast milk were examined by inductively coupled plasma mass spectrometry, and the mean measurements were1.19 ± 1.53 ppm for Pb, 0.73 ± 0.58 ppm for As, 0 ± 0.20 ppm for Hg, and 0.45 ± 0.23 ppm for Cd. This study indicates that the levels of these contaminants in breast milk samples obtained in Famagusta District are well within the acceptable levels. However, the presence of AFM1 and heavy metals still may pose risks for infant health.

ESPEN guideline: Clinical nutrition in inflammatory bowel disease

INTRODUCTION

The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD).

METHODOLOGY

The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).

Influence of maternal breast milk ingestion on acquisition of the intestinal microbiome in preterm infants

BACKGROUND

The initial acquisition and early development of the intestinal microbiome during infancy are important to human health across the lifespan. Mode of birth, antibiotic administration, environment of care, and nutrition have all been shown to play a role in the assembly of the intestinal microbiome during early life. For preterm infants, who are disproportionately at risk of inflammatory intestinal disease (i.e., necrotizing enterocolitis), a unique set of clinical factors influence the establishment of the microbiome. The purpose of this study was to establish the influence of nutritional exposures on the intestinal microbiome in a cohort of preterm infants early in life.

RESULTS

Principal component analysis of 199 samples from 30 preterm infants (<32 weeks) over the first 60 days following birth showed that the intestinal microbiome was influenced by postnatal time (p < 0.001, R ² = 0.13), birth weight (p < 0.001, R ² = 0.08), and nutrition (p < 0.001, R ² = 0.21). Infants who were fed breast milk had a greater initial bacterial diversity and a more gradual acquisition of diversity compared to infants who were fed infant formula. The microbiome of infants fed breast milk were more similar regardless of birth weight (p = 0.049), in contrast to the microbiome of infants fed infant formula, which clustered differently based on birth weight (p < 0.001). By adjusting for differences in gut maturity, an ordered succession of microbial phylotypes was observed in breast milk-fed infants, which appeared to be disrupted in those fed infant formula. Supplementation with pasteurized donor human milk was partially successful in promoting a microbiome more similar to breast milk-fed infants and moderating rapid increases in bacterial diversity.

CONCLUSIONS

The preterm infant intestinal microbiome is influenced by postnatal time, birth weight, gestational age, and nutrition. Feeding with breast milk appears to mask the influence of birth weight, suggesting a protective effect against gut immaturity in the preterm infant. These findings suggest not only a microbial mechanism underpinning the body of evidence showing that breast milk promotes intestinal health in the preterm infant but also a dynamic interplay of host and dietary factors that facilitate the colonization of and enrichment for specific microbes during establishment of the preterm infant microbiota.

Cow's milk allergy: towards an update of DRACMA guidelines

BACKGROUND

In 2010, the diagnosis and treatment of IgE-mediated CMA were systematized in a GRADE guideline.

OBJECTIVES & METHODS

After 6 years, the state of the knowledge in diagnosis and treatment of CMA has largely evolved. We summarize here the main advances, and exemplify indicating some specific points: studies aimed at better knowledge of the effects of breastfeeding and the production of new special formulae intended for the treatment of CMA. The literature (PubMed/MEDLINE) was searched using the following algorithms: (1) [milk allergy] AND diagnosis; (2) [milk allergy] AND [formul*] OR [breast*], setting the search engine [6-years] time and [human] limits. The authors drew on their collective clinical experience to restrict retrieved studies to those of relevance to a pediatric allergy practice.

RESULTS

Several clinical studies did address the possibility to diagnose CMA using new tools in vitro and in vivo, or to diagnose it without any evaluation of sensitization. Some studies also addressed the clinical role of formulae based on milk hydrolysates, soy, or rice hydrolysates in the treatment of CMA. Many studies have elucidated the effects of selective nutrients in breastfed infants on their immunologic and neurologic characteristics.

CONCLUSIONS

Evidence-based diagnostic criteria should be identified for non-IgE-mediated CMA. Debate is ongoing about the best substitute for infants with CMA. In particular, Hydrolyzed Rice Formulae have been widely assessed in the last six years. In the substitute choice, clinicians should be aware of recent studies that can modify the interpretation of the current recommendations. New systematic reviews and metanalyses are needed to confirm or modify the current DRACMA recommendations.

The Effect of Holder Pasteurization on Activin A Levels in Human Milk

INTRODUCTION

There is evidence that mother's own milk is the best nutrient in terms of multiorgan protection and infection prevention. However, when maternal milk is scarce, the solution can be represented by donor milk (DM), which requires specific storage procedures such as Holder Pasteurization (HoP). HoP is not free from side effects since it is widely known that it causes qualitative/quantitative changes in milk composition, particularly in the protein content. Therefore, the aim of this study is to investigate the effects of HoP on Activin A, a neurobiomarker known to play an important role in the development and protection of the central nervous system.

METHODS

In 24 mothers who delivered preterm (n = 12) and term (n = 12) healthy newborns, we conducted a pretest/test study where the milk donors acted as their own controls. Each sample was divided into two parts: the first was frozen at -80°C (Group 1); the second was Holder-pasteurized before freezing at -80°C (Group 2). Activin A was quantified using an ELISA test.

RESULTS

Activin A was detected in all samples. There were no significant differences (p > 0.05) between the two groups, also when the analysis was stratified for gestational age at delivery and milk maturation degree (p > 0.05, for both).

CONCLUSION

The present findings on the absence of any side effects of HoP on the milk concentration of Activin A offer additional support to the efficacy of HoP in DM storage. Our data open up to further investigations on neurobiomarkers' assessment in human milk and their preanalytical stability according to storage procedures.

Breastfeeding Support in Spanish Neonatal Intensive Care Units and the Baby-Friendly Hospital Initiative

BACKGROUND

The Baby-Friendly Hospital Initiative (BFHI) has a positive effect on breastfeeding in maternity wards; however, few studies have examined to what degree it affects care in neonatal intensive care units (NICUs). Recently, the BFHI has been adapted to the NICUs (Neo-BFHI).

OBJECTIVE

This study aimed to compare breastfeeding support in Spanish NICUs in hospitals with BFHI accreditation or in the process of being accredited (group 1) with NICUs in hospitals that have not yet begun this initiative (group 2).

METHODS

A validated questionnaire on breastfeeding support was distributed to level II and III NICUs in Spanish public hospitals. A univariate analysis and an analysis adjusted for the number of beds in NICUs were conducted. The results of the analysis of 36 breastfeeding support measures are presented in accordance with the Ten Steps to Successful Breastfeeding adapted to NICUs.

RESULTS

Of the 141 participating NICUs, 129 (91%) responded to the questionnaire: 38 NICUs from group 1 and 91 NICUs from group 2. Group 1 had implemented a higher number of breastfeeding support measures than group 2. There were significant differences in 18 measures related to steps 2, 4, 5, 7, and 8 of the Neo-BFHI. In addition, a comparison of NICUs in hospitals with full accreditation (7 of 129) with those in group 2 revealed significant differences in 7 measures pertaining to steps 2, 5, 8, and 9.

CONCLUSION

The Spanish NICUs in hospitals with BFHI accreditation or in the process of being accredited have better implementation of practices to promote and support breastfeeding.

Breast-Milk Cortisol and Cortisone Concentrations Follow the Diurnal Rhythm of Maternal Hypothalamus-Pituitary-Adrenal Axis Activity

BACKGROUND

Very preterm infants often receive donor milk from mothers who deliver at term, but its composition differs from that of their own mother's milk. Because breast-milk glucocorticoids can support developing neonates, we explored concentration variability within and between mothers.

OBJECTIVE

We hypothesized that breast-milk glucocorticoid concentrations would be higher after very preterm delivery [gestational age (GA) <32 wk; study 1] and would follow the diurnal rhythm of maternal adrenocortical activity (study 2).

METHODS

Study 1 assessed differences in milk cortisol, cortisone, and the cortisone-to-(cortisol+cortisone) ratio of mothers who delivered at (median) GA: 28.6 wk or at term weekly during the first month postpartum. Study 2 assessed variations in milk cortisol, cortisone, and the cortisone-to-(cortisol+cortisone) ratio over 24 h, and tested Pearson correlations between milk and salivary concentrations in mothers who delivered at term (median GA: 38.9 wk) during week 4 postpartum. In these studies, foremilk glucocorticoids were measured by liquid chromatography-tandem mass spectrometry. Associations of milk cortisol, milk cortisone, and the milk cortisone-to-(cortisol+cortisone) ratio with prematurity (study 1) or collection time (study 2) were studied with longitudinal data analyses.

RESULTS

In study 1, giving birth to a very preterm infant was associated with reductions in milk cortisol and cortisone concentrations of 50% (β: 0.50; 95% CI: 0.26, 0.99; P = 0.05) and 53% (β: 0.53; 95% CI: 0.30, 0.93; P = 0.03), respectively, when adjusted for collection time. In study 2, concentrations of milk cortisol and cortisone were associated with collection time (both P < 0.01), peaking at ∼0700. Milk and salivary concentrations of cortisol (r = 0.92, P < 0.01) and cortisone (r = 0.93, P < 0.01) as well as the cortisone-to-(cortisol+cortisone) ratio (r = 0.64, P < 0.01) were correlated with one another.

CONCLUSIONS

Breast-milk glucocorticoid concentrations follow the diurnal rhythm of maternal hypothalamus-pituitary-adrenal axis activity and are lower in mothers who deliver very preterm.

Association between full breastfeeding, timing of complementary food introduction, and iron status in infancy in Germany: results of a secondary analysis of a randomized trial

PURPOSE

Considering the low content in breast milk breastfed infants might be at particular risk for depleted iron stores after the first months of life. This study evaluates the association of the mode of milk feeding and the timing of complementary food (CF) introduction with parameters of iron status in term healthy infants in Germany.

METHODS

In this secondary analysis of a randomized controlled trial, parents recorded all foods consumed by their infants from the age of 8 weeks onwards. Mothers were advised on the German food-based dietary guidelines for infants. Accordingly, CF was introduced between the fifth and seventh month of age. Blood samples were taken at 4 and at 10 months of age for analyses of iron status parameters. Iron depletion was defined as serum ferritin <12 ng/mL.

RESULTS

The iron intake was lower in breastfed infants (n = 50) than in formula fed (n = 23) with decreasing differences during the course of infancy. At 10 months of age, most iron parameters were not associated with the mode of milk feeding or the timing of CF introduction. At this age, the iron depletion prevalence was >34% without general differences according to the mode of milk feeding or the timing of CF introduction.

CONCLUSION

The high prevalence of depleted iron stores observed in both breastfed and formula-fed infants illustrates the need for further studies to improve our understanding of the optimal iron intake and sensitive parameters of iron status in infancy.

Associations between exclusive breastfeeding and physical fitness during childhood

PURPOSE

Exposure to breastfeeding improves the survival, health, and development of children; therefore, breast milk is recommended as the exclusive nutrient source for feeding term infants during the first 6 months. This cross-sectional study aimed to determine the possible association between exposure to exclusive breastfeeding and physical fitness performance in children and, if so, whether this association is influenced by the breastfeeding duration.

METHODS

A total of 2853 (52.3 % girls) European children from the IDEFICS study aged 6-11 years with complete data on physical fitness (cardiorespiratory fitness, muscular strength, flexibility, balance, speed) and exclusive breastfeeding duration (never, 1-3, 4-6, 7-12 months) were included in the present study. Multivariate and mixed linear regression models were estimated and adjusted for sex, age, birth weight, diet, physical activity, body mass index, and parental factors (age, body mass index, educational attainment).

RESULTS

We found a positive association between exclusive breastfeeding and lower-body explosive strength (β = 0.034) as well as flexibility (β = 0.028). We also found a positive association between breastfeeding and balance in boys (β = 0.039), while this association was negative in girls (β = -0.029). To improve lower-body explosive strength, 1-3 months of exclusive breastfeeding were enough; a longer duration did not lead to increasing benefit. In contrast, 4-6 months of breastfeeding were necessary to have any benefit on flexibility or balance, although this became nonsignificant after adjustment for body mass index and physical activity.

CONCLUSIONS

Exclusive breastfeeding seems a natural way of slightly improving some physical fitness components (mainly lower-body muscle strength) and thus future health.