Changing partners: the dance of infant formula changes

Whole Goat Milk-Based Formula versus Whey-Based Cow Milk Formula: What Formula Do Infants Enjoy More?-A Feasibility, Double-Blind, Randomized Controlled Trial

(1) Background: While goat milk formula (GMF) is an alternative to cow milk formula (CMF), infants' preferences for one over the other have not been formally assessed. Specifically, our aim in this study was to determine whether infants experience fewer feeding behavior problems with whole milk-based GMF than with conventional whey-based CMF. (2) Methods: This was a multicenter, double-blind, randomized controlled trial with two-arm parallel assignment conducted in six pediatricians' offices in or near Paris, France, between June 2018 and 31 December 2021. Overall, 64 healthy infants (≤4 months old), predominantly formula-fed, were randomly assigned to either the whole milk-based GMF (n = 33) or whey-based CMF (n = 31) arm. Parents completed the Baby Eating Behavior Questionnaire (BEBQ) and the modified QUALIN questionnaire to evaluate infant feeding behavior and quality of life (psychomotor and socioemotional development), respectively, at inclusion (1 to 5 days before milk delivery) and the final visit (day 28 ± 3 after milk delivery). Informed consent was obtained for all recruited patients, and an ethical committee approved the study. (3) Results: Changes in BEBQ Enjoyment of Food and Slowness in Eating subscale scores from inclusion to final visit did not differ between arms. However, there were significant improvements in subscale scores for Food Responsiveness (GMF: 0.15 ± 1; CMF: -0.48 ± 0.81; p = 0.010) and General Appetite (GMF: 0.26 ± 1.2; CMF: -0.48 ± 0.88; p = 0.012), and modified QUALIN (GMF: 4.6 ± 9.4; CMF: -0.40 ± 7.6; p = 0.03) scores in favor of the GMF group. (4) Conclusions: In this double-blind, randomized controlled trial, GMF-fed infants exhibited a greater general appetite than CMF-fed infants, possibly due to differences in the composition of these formulas (i.e., protein and lipid profiles). In addition, GMF-fed infants enjoyed a better quality of life. There was no difference in food enjoyment between groups. These findings suggest that whole-milk-based GMF could be an attractive alternative to whey-based CMF. Clinical trial registration: NCT03488758 (clinicaltrials.gov).

Limosilactobacillus reuteri DSM 17938-Containing Infant Formulas and the Associations with Gastrointestinal Tolerance: A Cross-Sectional Observational Study

Limosilactobacillus (L.; previously Lactobacillus) reuteri has been shown to influence gastrointestinal (GI) tolerance. This study was a secondary analysis of GI tolerance data from a multi-country, cross-sectional, observational study in healthy infants using the validated Infant Gastrointestinal Symptom Questionnaire (IGSQ) and a gut comfort questionnaire. Breastfed infants (BFI; n = 760) were compared to formula-fed infants receiving either L. reuteri-containing formula (FFI + LR; n = 470) or standard formula without any probiotic or prebiotic (FFI-Std; n = 501). The IGSQ composite scores (adjusted mean ± SE) in FFI + LR (22.17 ± 0.39) was significantly lower than in FFI-Std (23.41 ± 0.37) and similar to BFI (22.34 ± 0.30;), indicating better GI tolerance in FFI + LR than in FFI-Std. Compared with FFI-Std, FFI + LR had lower reports of difficulty in passing stools (11% vs. 22%; adjusted-odds ratio (OR) (95%CI) = 0.46 (0.31-0.68)), fewer hard stools (mean difference = -0.12 (-0.21, -0.02)) and less physician-confirmed colic (OR = 0.61 (0.45-0.82)), and similar to BFI. Parent-reported crying time (mean difference = -0.15 (-0.28, -0.01)), frequency of spitting-up/vomiting (mean difference = -0.18 (-0.34, -0.03)), volume of spit-up (mean difference = -0.20 (-0.32, -0.08)) and fussiness due to spitting-up/vomiting (mean difference = -0.17 (-0.29, -0.05)) were lower in FFI + LR versus FFI-Std and similar to BFI. In this study, L. reuteri-containing formula was associated with improved digestive tolerance and behavioral patterns.

Soy-Based Infant Formula Feeding and Uterine Fibroid Development in a Prospective Ultrasound Study of Black/African-American Women

BACKGROUND

Uterine fibroids are highly prevalent, benign tumors. They are the leading indication for hysterectomy, and Black women are disproportionally burdened. Soy-based infant formula contains phytoestrogens, and exposure during sensitive developmental windows may adversely affect the developing uterus; early phytoestrogen treatment in rodent studies led to detrimental uterine effects, including increased fibroid risk in Eker rats. Limited epidemiological studies also have suggested increased fibroid development with soy formula infant feeding.

OBJECTIVE

The goal of this study was to examine the association between soy formula feeding in infancy and fibroid development in adulthood.

METHODS

We evaluated this association among 1,610 Black/African-American women age 23-35 y in the Study of Environment, Lifestyle & Fibroids (SELF). Soy formula feeding data was gathered directly from the participants' mothers (89%). A standardized ultrasound examination was conducted during 4 clinic visits over 5 y to detect fibroids ≥0.5cm in diameter. We used Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between soy formula feeding and incident fibroids adjusted for early-life and adult factors. Fibroid growth was calculated as change in log-volume for fibroids matched at successive visits.

RESULTS

Of 1,121 fibroid-free participants at baseline, 150 (13%) were ever fed soy formula as infants, and 269 (24%) developed incident fibroids. We did not observe an association between ever being fed soy formula and incident fibroid risk (HR=1.08; 95% CI: 0.75, 1.54). However, participants fed soy formula within 2 months of birth and for >6 months (n=53) had an elevated risk of fibroid incidence in comparison with those never fed soy formula (HR=1.56; 95% CI: 0.92, 2.65). Fibroid growth rates did not differ.

DISCUSSION

Adding support to limited human data, this prospective fibroid study found that soy-based formula feeding during infancy was associated with a suggestive increase in risk of ultrasound-identified incident fibroids in adulthood. https://doi.org/10.1289/EHP11089.

Efficacy of Soy-Based Formulas in Alleviating Gastrointestinal Symptoms in Infants With Milk-Based Formula Intolerance: A Randomized Clinical Trial

A randomized, blinded pilot clinical study was conducted to assess gastrointestinal (GI) tolerance in healthy, full-term infants (2-9 weeks old), whose pediatricians recommended a formula change due to perceived cow's milk formula intolerance. Infants were randomized and exclusively fed either a commercial control soy formula (SF; n = 22), an experimental partially hydrolyzed SF (10% hydrolyzed, n = 23), or a 5% hydrolyzed SF (n = 26) for 2 weeks. Age-matched reference cohorts (n = 72) with no GI intolerance on milk-based formula were assessed in parallel. Results indicated that all SF-fed groups contributed to reduction (P < .05) in common GI tolerance symptoms to levels not different from the non-symptomatic reference cohort at study end. The control SF group had more reduced fussiness, gas, and crying and higher formed stools versus hydrolyzed SF groups. In conclusion, the study suggests that SFs reduced GI intolerance symptoms in otherwise healthy infants with poor tolerance on milk-based formulas.

Clinical Response to Two Formulas in Infants with Parent-Reported Signs of Formula Intolerance: A Multi-Country, Double-Blind, Randomized Trial

Background:

Signs of feeding intolerance are common in formula-fed infants. We evaluated the clinical response to a partially hydrolyzed 100% whey protein formula with high sn-2 palmitate and reduced lactose (FA) and to an alpha-lactalbumin-enriched whey-predominant intact protein formula with full lactose (FB) in healthy full-term infants with parent-reported signs of feeding intolerance.

Methods:

In a double-blind, parallel-group trial in 6 Asian study centers, exclusively formula-fed infants aged 30 to 90 days, whose parents reported fussiness-crying for ≥2 hours/day plus gassiness and/or stooling difficulty, and intended to switch formula, were randomly assigned to FA (n = 130) or FB (n = 129) for 14 days. Primary endpoint was daily duration of fussiness-crying. Secondary endpoints included gassiness, spitting-up, vomiting, sleep pattern, Infant Gastrointestinal Symptom Questionnaire (IGSQ) Index, infant temperament and maternal anxiety.

Results:

Mean ± SE minutes/day of fussiness-crying in the 256 analyzed infants (FA, n = 127 and FB, n = 129) substantially decreased from baseline to study end in FA (291 ± 14 to 140 ± 8; –52%, P < .001), and FB (313 ± 14 to 153 ± 11, –51%, P < .001) with no difference between groups. Similarly, gassiness, spitting-up, vomiting and sleep pattern significantly improved by study end for both formulas. Mean ± SE IGSQ index scores significantly decreased from baseline to study end (FA: 44.5 ± 0.9 to 28.6 ± 0.7; FB: 44.5 ± 0.8 to 29.0 ± 0.7; P < .001) with no differences between groups. Infant temperament and maternal anxiety also improved significantly in both groups by study end.

Conclusion:

Switching from standard, full-lactose, intact whey/casein infant formulas to either study formula resulted in an improvement of gastrointestinal symptoms and associated behaviors in infants with signs of feeding intolerance.

Trial Registration:

https://clinicaltrials.gov, NCT02021058

2'-Fucosyllactose Is Well Tolerated in a 100% Whey, Partially Hydrolyzed Infant Formula With Bifidobacterium lactis: A Randomized Controlled Trial

Human milk oligosaccharides are important components of breast milk. We evaluated feeding tolerance of the human milk oligosaccharide 2′-fucosyllactose (2′FL) in a 100% whey, partially hydrolyzed infant formula with the probiotic Bifidobacterium animalis ssp lactis strain Bb12 (B lactis; Test) as compared with the same formula without 2′FL (Control) in a randomized controlled trial of healthy infants enrolled at 2 weeks of age (±5 days). After 6 weeks of feeding the assigned formula, the primary outcome of tolerance was assessed using the Infant Gastrointestinal Symptom Questionnaire. Stooling, vomiting, spit-up, crying, and fussing were compared between groups. Seventy-nine infants were enrolled and 63 completed the study per protocol (30 Test, 33 Control). Infant Gastrointestinal Symptom Questionnaire scores were similar between groups (Test 20.9 ± 4.8, Control 20.7 ± 4.3, P = .82). Partially hydrolyzed infant formula with 2′FL and B lactis is tolerated well, as confirmed by a validated multi-symptom index.

A Pooled Analysis of Growth and Tolerance of Infants Exclusively Fed Partially Hydrolyzed Whey or Intact Protein-Based Infant Formulas

Background

For infants who are partially or exclusively fed infant formula, many options exist with compositional differences between formulas making choices difficult for caregivers and healthcare professionals. The protein in routine infant formulas differs by the source, fraction of cow's milk protein used, and degree of hydrolysis. All commercially available regulated infant formulas support growth and development, but different stool patterns have been observed based on formula composition. A pooled analysis of seven clinical trials was conducted to examine growth, stool consistency, and stool frequency of infants fed an intact cow's milk-based formula (CMF) or a partially hydrolyzed whey formula (PHF-W) from a single manufacturer. Methods. Individual subject data from seven infant formula growth studies (3 CMF, 4 PHF-W) were pooled and analyzed. All studies included healthy, full-term, formula-fed infants enrolled at 14 days of age with outcomes assessed over 4 months. Gains in weight and length to 4 months were analyzed using linear regression accounting for clustering within study. Outcomes of caregiver-reported stool consistency and frequency were analyzed using a longitudinal multinomial model.

Results

Data from 511 infants were included (197 CMF, 314 PHF-W). There were no differences in weight gain between groups. There was no difference in length gain in girls fed PHF-W while boys fed PHF-W had a significant difference of +0.016 cm/month compared to boys fed CMF. Infants fed PHF-W had a significantly higher probability of soft and lower probability of hard stools as compared to infants fed CMF at each time point (p<0.001). Stool frequency was similar between groups.

Conclusions

Infants fed CMF and PHF-W exhibit appropriate growth with comparable gains in weight and length through 4 months. More soft and fewer hard stools are observed in infants fed PHF-W compared to CMF. This difference could help to inform decision-making when choosing an infant formula.

Soy-based Infant Formula Feeding and Heavy Menstrual Bleeding Among Young African American Women

BACKGROUND

Phytoestrogen exposure from soy formula feeding during infancy may disrupt reproductive system development, resulting in altered menstrual bleeding in adulthood.

METHODS

We investigated this relationship in a cohort of 1,696 young African American women using enrollment data from the Study of Environment, Lifestyle, & Fibroids (2010-2012). Questionnaire data on soy formula feeding were available for 1,553 participants, 89% based on mother's report. Menstrual bleeding outcomes including those indicative of heavy menstrual bleeding were ascertained by interview. We estimated relative risks (RRs) and 95% confidence intervals (CI) for associations between soy formula feeding and menstrual bleeding outcomes using log-binomial regression and log-multinomial regression, comparing participants ever fed and never fed soy formula.

RESULTS

We observed associations between soy formula feeding and variables indicating a history of heavy menstrual bleeding, including ever experiencing heavy, gushing-type bleeding (RR: 1.2, 95% CI: 1.0, 1.4), ever use of nonsteroidal anti-inflammatory drugs for heavy bleeding (RR: 1.3, 95% CI: 1.0, 1.6), and ever use of a contraceptive method for heavy bleeding (RR: 1.2, 95% CI, 0.9, 1.6). Among the subset of participants with menses in the past year who did not use medication that may alter menstrual flow (n = 762), our data suggested that soy formula feeding was associated with heavier flow and the adverse impact of menstrual bleeding on quality of life, but CIs were wide.

CONCLUSIONS

Our data suggested that soy formula feeding is associated with heavy menstrual bleeding. Our results support the idea that infancy is a susceptible developmental window for female reproductive function.

Soy-Based Therapeutic Baby Formulas: Testable Hypotheses Regarding the Pros and Cons

Soy-based infant formulas have been consumed in the United States since 1909, and currently constitute a significant portion of the infant formula market. There are efforts underway to generate genetically modified soybeans that produce therapeutic agents of interest with the intent to deliver those agents in a soy-based infant formula platform. The threefold purpose of this review article is to first discuss the pros and cons of soy-based infant formulas, then present testable hypotheses to discern the suitability of a soy platform for drug delivery in babies, and finally start a discussion to inform public policy on this important area of infant nutrition.

Infant formula feeding practices in a prospective population based study

Background

It is recommended that formula-fed infants are given standard whey-based infant formula throughout the first year of life, unless otherwise advised by healthcare professionals. To our knowledge it has not yet been explored if parents are using a whey-based infant formula throughout the first 12 months of life. Reasons for parental choice of formula are also unknown. Therefore, the objective of this paper was to describe parental administration of whey-based and non whey-based infant formula in the first year of life.

Methods

Data collected as part of the Cork BASELINE Birth Cohort Study examined infant feeding practices at 2, 6 and 12 months of age. Descriptive analysis explored infant feeding practices and parental reasons for changing from a whey-based to a non whey-based infant formula. Multiple logistic regression investigated parental and infant characteristics associated with the use of whey-based infant formula.

Results

In total, 62.4%, 40.4% and 12.8% parent(s) at 2, 6 and 12 months, respectively, gave their infant whey-based infant formula. No parental or infant characteristic was found to consistently influence the use of whey-based infant formula. The most common reason reported by parent(s) for changing their infant’s formula to a non whey-based formula was that they perceived their baby as being hungry.

Conclusion

The majority of parent(s) commence their infants on whey-based formula, but most change to non whey-based formula before 12 months of age. Parental perception of infant satiety and not healthcare advice was the most common reason for changing from a whey-based to a non whey-based infant formula. Additional research is now required to investigate the effect of whey-based and non whey-based infant formula on infant growth.

What's in the Bottle? A Review of Infant Formulas

Infant formulas are designed to be a substitute for breast milk. Since they are sole source of nutrition for growing and developing infants, they are highly regulated by the government. All ingredients in infant formulas must be considered "generally recognized as safe." Manufacturers are continually modifying their products to make them more like breast milk. Functional ingredients added to infant formula include long-chain polyunsaturated fatty acids, nucleotides, prebiotics, and probiotics. The most common breast milk substitutes are standard cow's milk-based term infant formulas, which include subcategories of organic and breast milk supplementation, and come in standard dilutions of 19 or 20 calories per ounce. In addition to standard cow's milk-based term infant formulas, there is a line of term infant formulas marketed for signs and symptoms of intolerance. These products include modifications in lactose content, partially hydrolyzed protein, added probiotics, or added rice starch. There are also specialized formulas for medical conditions such as prematurity, gastrointestinal disorders, allergy, disorders of fat metabolism, and renal insufficiency. Infants on specialty formulas should be monitored closely by medical professionals. Formulas come in ready-to-feed, liquid concentrate, and powder forms. Each offers advantages and disadvantages. Each step in the formula mixing process or each manipulation required for the feeding is another opportunity to introduce bacteria to the formula. There are guidelines for preparing formula in institutions. Standard dilution and mixing instructions are different for each formula, so individual recipes are needed. Caregivers should also be educated on proper hygiene when preparing formula at home.

Soy-Based Infant Formula Feeding and Ultrasound-Detected Uterine Fibroids among Young African-American Women with No Prior Clinical Diagnosis of Fibroids

BACKGROUND

Early-life soy phytoestrogen exposure has been shown in Eker rats to increase uterine fibroid incidence in adulthood. Two large epidemiologic cohorts have provided some support for increased fibroid risk with infant soy formula feeding in women, but both cohorts relied on self-report of clinically diagnosed fibroids.

OBJECTIVE

We evaluated the relationship between infant soy formula feeding and ultrasound-detected fibroids.

METHODS

The Study of Environment, Lifestyle & Fibroids (SELF) is an ongoing cohort study of 1,696 African-American women ages 23-34 years with baseline ultrasound screening to detect and measure fibroids ≥ 0.5 cm in diameter. Questionnaire data on soy formula feeding during infancy was ascertained for 1,553 participants (89% based on mother's report), of whom 345 were found to have fibroids. We estimated the association between soy formula feeding and fibroid prevalence and tumor number using log-binomial regression. Among those with fibroids, we compared fibroid size between soy formula-exposed and unexposed women using multivariable linear regression.

RESULTS

We did not observe an association between soy formula feeding and fibroid prevalence [adjusted prevalence ratio (aPR) 0.9, 95% CI: 0.7, 1.3]. Nor were exposed women with fibroids more likely to have ≥ 2 tumors than unexposed women with fibroids (aPR 1.0, 95% CI: 0.7, 1.6). However, exposed women with fibroids had significantly larger fibroids than unexposed women with fibroids. On average, soy formula feeding was associated with a 32% increase in the diameter of the largest fibroid (95% CI: 6%, 65%) and a 127% increase in total tumor volume (95% CI: 12%, 358%).

CONCLUSIONS

Our observation that women fed soy formula as infants have larger fibroids than unexposed women provides further support for persistent effects of early life phytoestrogen exposure on the uterus.

CITATION

Upson K, Harmon QE, Baird DD. 2016. Soy-based infant formula feeding and ultrasound-detected uterine fibroids among young African-American women with no prior clinical diagnosis of fibroids. Environ Health Perspect 124:769-775; http://dx.doi.org/10.1289/ehp.1510082.

Signs and symptoms associated with digestive tract development

OBJECTIVE

To analyze the development and prevalence of gastrointestinal signs and symptoms associated with the development of the digestive tract, and to assess the measures aimed to reduce their negative impacts.

SOURCE OF DATA

Considering the scope and comprehensiveness of the subject, a systematic review of the literature was not carried out. The Medline database was used to identify references that would allow the analysis of the study topics.

SYNTHESIS OF RESULTS

Infants frequently show several gastrointestinal signs and symptoms. These clinical manifestations can be part of gastrointestinal functional disorders such as infantile colic, infant regurgitation, and functional constipation. Allergy to cow's milk protein and gastroesophageal reflux disease are also causes of these clinical manifestations and represent an important and difficult differential diagnosis. The diseases that course with gastrointestinal signs and symptoms can have an impact on family dynamics and maternal emotional status, and may be associated with future problems in the child's life. Comprehensive pediatric care is essential for diagnosis and treatment. Maternal breastfeeding should always be maintained. Some special formulas can contribute to the control of clinical manifestations depending on the established diagnosis.

CONCLUSION

During the normal development of the digestive tract, several gastrointestinal signs and symptoms may occur, usually resulting from functional gastrointestinal disorders, gastroesophageal reflux disease, and allergy to cow's milk protein. Breastfeeding should always be maintained.

Preventive effects of oral probiotic on infantile colic: a prospective, randomised, blinded, controlled trial using Lactobacillus reuteri DSM 17938

Infants were recruited in four centres in North-West Italy. 138 infants were assessed for eligibility, 113 ones underwent randomisation and 105 completed the study. Newborns aged less than 10 days of life, with gestational age between 37 and 42 weeks, birth weight from 2,500 to 4,300 g and normal physical examination were recruitable. Premature infants and infants affected by outcomes of perinatal hypoxia or necrotising enterocolitis have been excluded. Patients were randomly assigned to receive five drops containing Lactobacillus reuteri DSM 17938 (108 cfu) with 400 UI of vitamin D3 or only 400 UI of vitamin D3 daily. The primary endpoints concern the administration of pain relieving agents (cimetropium bromide at least three times per week or simethicone at least five times per week) from baseline to 12 weeks. Additional analyses were done on the percentage of infants that switched from an exclusive breastfeeding to a partial or exclusive formula feeding from baseline to 12 weeks. Data concerning the number of calls to the paediatricians and the number of visits at paediatricians' ambulatories due to infantile colic have been collected by paediatrician and analysed. Comparing the two groups, the relative risk was 0.04 (95% confidence interval (CI)=0.01-0.31) for cimetropium bromide, 0.24 (95% CI=0.14-0.41) for simethicone and 0.37 (95% CI=0.17-0.80) for the administration of infant formula, showing a protective action of L. reuteri. The treatment group showed a lower number of paediatric consultations related to episodes of infant colic than the control group (P<0.0001). L. reuteri DSM 17938 supplementation at the tested dosage could reduce parental discomfort due to infantile colic. The consumption of this probiotic is associated with a reduction of paediatric consultations for infantile colic, as well as use of pain relieving agents and of infant formula.

Validation of a Parent Report Questionnaire: The Infant Gastrointestinal Symptom Questionnaire

OBJECTIVE

To evaluate the reliability and validity of the Infant Gastrointestinal Symptom Questionnaire (IGSQ), a tool to assess feeding tolerance in infants.

METHODS

Qualitative methods were used to develop IGSQ content across 5 symptom clusters, yielding a 13-item index of parent-reported infant digestion and elimination behaviors over the prior 7 days. Classical psychometric methods evaluated factor structure, interrater and retest reliability, and validity in 4 prospective studies of 836 infants.

RESULTS

Interrater and retest reliability were acceptable to good. IGSQ Index score was highly correlated (r = 0.89) with daily parent reports. IGSQ scores were significantly different between infants whose parents planned to switch formulas because of perceived feeding problems and those without parental concerns.

CONCLUSIONS

The IGSQ is a practical, reliable, and valid method for assessment of infant gastrointestinal-related behaviors. Its use in clinical studies can provide empirical evidence to advance parent education regarding both normal and clinically meaningful feeding-related behaviors.

Lactose-Free Milk or Soy-Based Formulas Do Not Improve Caregivers' Distress or Perceptions of Difficult Infant Behavior

OBJECTIVES

The aim of the study was to test the hypothesis that caregiver-reported difficulties in infant behavior and caregivers' distress will significantly improve on lactose-free (LF) milk-based or LF soy-based formulas compared with a milk-based, lactose-containing formula.

METHODS

In this double-blind randomized controlled trial, infants (mean age: 4.97 weeks) with caregiver-reported feeding problems on a milk-based lactose-containing formula were randomized to receive either LF milk-based (n = 96), LF soy-based (n = 97), or milk-based, lactose-containing (n = 103) formula. Study formula was infants' sole item of diet for 14 days. Infants' caregivers completed measures of infant behavior and caregivers' distress for the week preceding baseline and again for the week preceding the 14-day follow-up.

RESULTS

Infants who received LF milk or LF soy-based formulas did not significantly differ from those who received milk-based, lactose-containing formula on follow-up caregiver-reported measures of infant difficultness from the Infant Characteristics Questionnaire, F(2, 277) = 0.83, nor on measures of caregivers' distress, assessed with measures of caregivers' mental health and parenting efficacy, F(2, 285) = 0.73-1.07. Across the 3 formula groups, scores on outcome measures significantly improved from baseline to follow-up (P < 0.001).

CONCLUSIONS

Our study does not support LF milk or LF soy-based formulas to alleviate common infant behaviors such as fussiness, crying, or need for attention. Moreover, the data suggest that some difficulties in infant behaviors, as well as caregivers' distress and perceived efficacy in parenting difficult infants, may improve within a couple weeks of reporting difficulties to the pediatrician.

Milk protein-based infant formula containing rice starch and low lactose reduces common regurgitation in healthy term infants: a randomized, blinded, and prospective trial

OBJECTIVE

Spit-up (regurgitation) reduction with prethickened milk protein-based infant formulas containing rice starch has been clinically demonstrated in infants with heavy spit-ups but not in otherwise healthy normal infants with common spit-ups. The objective of this study was to evaluate growth, gastrointestinal tolerance, and efficacy to reduce common spit-up in normal, healthy term infants fed an investigational rice starch prethickened lactose-free milk protein-based infant formula.

METHODS

This double-blind, randomized, parallel study evaluated the investigational rice starch prethickened lactose-free (low lactose < 100 mg/L) milk protein-based infant formula compared to a standard, commercially available, iso-nutrient, lactose-containing (100% of carbohydrate) milk-based infant formula (control) for growth and gastrointestinal tolerance in healthy term infants (n = 132/group) fed from 14 ± 3 days to 112 days of age. Data were classified and analyzed as evaluable (EV; subjects completing study per protocol) or intent-to-treat data (ITT; all subjects with available data).

RESULTS

Growth as indicated by weight gain (primary variable) and formula intake were not significantly different (p > 0.05) between feeding groups (EV or ITT). Though both formulas were well tolerated, spit-up frequency was significantly lower (p < 0.05) in the rice versus control group by 53% at 28 days of age, 54% at 56 days, 48% at 84 days, and 32% at 112 days (EV). Importantly, infants in the rice group were 1.6 to 1.8 times more likely to report zero spit-up than infants in the control group. The rice group also had higher percentages of soft and yellow stools.

CONCLUSIONS

The rice starch prethickened lactose-free milk protein-based formula (rice) supported normal growth and safe use as the sole source of feeding for normal infants over the first 4 months of life. The rice formula was efficacious in providing a clinically relevant reduction of spit-up frequency in otherwise healthy term infants.

GI symptoms in infants are a potential target for fermented infant milk formulae: a review

Besides pre- and pro-biotic-containing infant formulae, fermented infant formulae are commonly used to relieve or prevent symptoms of gastrointestinal (GI) discomfort in young infants. During the fermentation process in cow's milk-based formulae, the beneficial bacteria modulate the product by forming several beneficial compounds, which contribute to the alleviation of the symptoms observed. This review summarizes the clinical evidence on the impact of fermented infant formulae on common pediatric GI-symptoms. The potential mechanisms involved are discussed: i.e., the lactose and protein (in-) digestibility, effects on gastric emptying and gut transit and modulation of the colonic microbiota. Although initial evidence indicates a beneficial effect of fermented formulae on GI discomfort in newborns, validation and confirmation of the clinical proof obtained so far is warranted, as well as further research to (more fully) understand the mode of action.

A hypothesis regarding the molecular mechanism underlying dietary soy-induced effects on seizure propensity

Numerous neurological disorders including fragile X syndrome, Down syndrome, autism, and Alzheimer’s disease are co-morbid with epilepsy. We have observed elevated seizure propensity in mouse models of these disorders dependent on diet. Specifically, soy-based diets exacerbate audiogenic-induced seizures in juvenile mice. We have also found potential associations between the consumption of soy-based infant formula and seizure incidence, epilepsy comorbidity, and autism diagnostic scores in autistic children by retrospective analyses of medical record data. In total, these data suggest that consumption of high levels of soy protein during postnatal development may affect neuronal excitability. Herein, we present our theory regarding the molecular mechanism underlying soy-induced effects on seizure propensity. We hypothesize that soy phytoestrogens interfere with metabotropic glutamate receptor signaling through an estrogen receptor-dependent mechanism, which results in elevated production of key synaptic proteins and decreased seizure threshold.

Soy infant formula and seizures in children with autism: a retrospective study

Seizures are a common phenotype in many neurodevelopmental disorders including fragile X syndrome, Down syndrome and autism. We hypothesized that phytoestrogens in soy-based infant formula were contributing to lower seizure threshold in these disorders. Herein, we evaluated the dependence of seizure incidence on infant formula in a population of autistic children. Medical record data were obtained on 1,949 autistic children from the SFARI Simplex Collection. An autism diagnosis was determined by scores on the ADI-R and ADOS exams. The database included data on infant formula use, seizure incidence, the specific type of seizure exhibited and IQ. Soy-based formula was utilized in 17.5% of the study population. Females comprised 13.4% of the subjects. There was a 2.6-fold higher rate of febrile seizures [4.2% versus 1.6%, OR = 2.6, 95% CI = 1.3–5.3], a 2.1-fold higher rate of epilepsy comorbidity [3.6% versus 1.7%, OR = 2.2, 95% CI = 1.1–4.7] and a 4-fold higher rate of simple partial seizures [1.2% versus 0.3%, OR = 4.8, 95% CI = 1.0–23] in the autistic children fed soy-based formula. No statistically significant associations were found with other outcomes including: IQ, age of seizure onset, infantile spasms and atonic, generalized tonic clonic, absence and complex partial seizures. Limitations of the study included: infant formula and seizure data were based on parental recall, there were significantly less female subjects, and there was lack of data regarding critical confounders such as the reasons the subjects used soy formula, age at which soy formula was initiated and the length of time on soy formula. Despite these limitations, our results suggest that the use of soy-based infant formula may be associated with febrile seizures in both genders and with a diagnosis of epilepsy in males in autistic children. Given the lack of data on critical confounders and the retrospective nature of the study, a prospective study is required to confirm the association.

Lactose-free milk protein-based infant formula: impact on growth and gastrointestinal tolerance in infants

Lactose, the major carbohydrate in human milk and standard milk-based formulas, provides energy for growth in infants. The use of lactose-free milk protein-based infant formulas has increased in the United States. However, clinical studies of their impact on growth, safety, and gastrointestinal tolerance in infants are limited. Thus, a prospective, blinded, randomized clinical trial was conducted in healthy, normal-term infants fed an experimental lactose-free milk protein-based formula (NoLAC; n = 63) versus a standard commercial lactose-containing milk-based formula (LAC; n = 65) for 112 days. Growth (weight, length, and head circumference) was similar and normal in both groups (weight gain: NoLAC = 31.1 ± 0.9 g/day, LAC = 29.4 ± 0.9 g/day, mean ± SEM; P = .895). Serum biochemistries for both groups were within infants' normal reference ranges. Both groups had comparable tolerance but the NoLAC group had softer stools and lower spit-ups. Thus, the study suggests that absence of lactose in milk-based formula does not adversely affect normal growth in term infants.

Mothers' experiences of bottle-feeding: a systematic review of qualitative and quantitative studies

OBJECTIVE

Most babies receive at least some formula milk. Variations in formula-feeding practices can have both short- and long-term health consequences. The literature on parents' experiences of bottle-feeding was systematically reviewed to understand how formula-feeding decisions are made.

METHODS

Relevant English-language papers, identified by searching 12 electronic databases, reference lists and related articles and by contacting first authors of included papers, were systematically searched for and appraised. The included studies were analysed and synthesised using a combination of narrative and thematic approaches. Consensus on the final inclusion, interpretation and synthesis of studies was reached across the research team.

RESULTS

Six qualitative studies and 17 quantitative studies (involving 13 263 participants) were included. Despite wide differences in study design, context, focus and quality, several consistent themes emerged. Mothers who bottle-fed their babies experienced negative emotions such as guilt, anger, worry, uncertainty and a sense of failure. Mothers reported receiving little information on bottle-feeding and did not feel empowered to make decisions. Mistakes in preparation of bottle-feeds were common. No studies examined how mothers made decisions about the frequency or quantity of bottle-feeds.

CONCLUSIONS

Inadequate information and support for mothers who decide to bottle-feed may put the health of their babies at risk. While it is important to promote breastfeeding, it is also necessary to ensure that the needs of bottle-feeding mothers are met.

Tolerance of a standard intact protein formula versus a partially hydrolyzed formula in healthy, term infants

BACKGROUND

Parents who perceive common infant behaviors as formula intolerance-related often switch formulas without consulting a health professional. Up to one-half of formula-fed infants experience a formula change during the first six months of life.

METHODS

The objective of this study was to assess discontinuance due to study physician-assessed formula intolerance in healthy, term infants. Infants (335) were randomized to receive either a standard intact cow milk protein formula (INTACT) or a partially hydrolyzed cow milk protein formula (PH) in a 60 day non-inferiority trial. Discontinuance due to study physician-assessed formula intolerance was the primary outcome. Secondary outcomes included number of infants who discontinued for any reason, including parent-assessed.

RESULTS

Formula intolerance between groups (INTACT, 12.3% vs. PH, 13.7%) was similar for infants who completed the study or discontinued due to study physician-assessed formula intolerance. Overall study discontinuance based on parent- vs. study physician-assessed intolerance for all infants (14.4 vs.11.1%) was significantly different (P = 0.001).

CONCLUSION

This study demonstrated no difference in infant tolerance of intact vs. partially hydrolyzed cow milk protein formulas for healthy, term infants over a 60-day feeding trial, suggesting nonstandard partially hydrolyzed formulas are not necessary as a first-choice for healthy infants. Parents frequently perceived infant behavior as formula intolerance, paralleling previous reports of unnecessary formula changes.

TRIAL REGISTRATION

clinicaltrials.gov: NCT00666120.

Clinical response to 2 commonly used switch formulas occurs within 1 day

Very fussy or extremely fussy infants were randomized to receive: soy-based formula (Soy: n = 82) or a partially hydrolyzed cow's milk protein (CMP), low-lactose formula (PHF: n = 77) in a multicenter, double-blind, randomized, parallel, prospective 28-day feeding trial. Body weight and infant formula tolerance were reported. Adverse events were recorded throughout the study. A significant reduction in mean scores of fussiness, gas, spit-up, and crying compared with baseline measures was observed in infants who received either Soy or PHF within 1 day of formula intake; improvement in symptoms was sustained by study end. Stool consistency remained constant through day 28 in the PHF group, whereas stools in the Soy group became more firm by day 2 and did not return to prestudy consistency. PHF, with a protein profile patterned more closely on human breast milk, improved symptoms of formula intolerance as well as soy-based formula.

Infant feeding patterns in the first 6 months: an assessment in full-term infants

BACKGROUND

The infant formula market has grown significantly and offers a wide range of products for the different stages of healthy infant growth. Healthy infants often go through a series of unnecessary changes of formulas. The present study aimed to identify the factors leading to switches to alternative formulas. We studied the feeding patterns in the first 6 months of babies born at term, particularly changes in infant formulas. We also investigated the reasons for choosing the first formula, infant formula changes, the addition of formulas to supplement breast-feeding, and various aspects related to formula thickening.

PATIENTS AND METHODS

Two hundred parents of babies ages 6 to 18 months were interviewed. The interviews included a detailed questionnaire and were conducted in child and maternal health care centers.

RESULTS

Forty-seven percent of these infants underwent changes in their formula in the first 6 months of life, most of which (67%) were to another cow's milk-based formula. The main reasons for switching a formula were regurgitation or vomiting (24%) followed by restlessness (18%). Lower z scores at birth and a higher Deltaz2 (z score at the time of the questionnaire minus z score at birth) were associated with significantly more formula changes. The impact of pediatricians and other health care professionals on the choice of infant nutrition was surprisingly negligible.

CONCLUSIONS

The most common reason for switching a formula was concern regarding common infantile symptoms or behavior patterns perceived by parents to be related to formula intolerance. The decision to switch formula was usually made by the parents without consulting a health professional.

Vegetable acceptance by infants: effects of formula flavors

Individual differences in acceptance patterns are evident as early as the child's first experiences with a particular food. To test hypothesis that the flavor of formula fed to infants modifies their acceptance of some foods, we conducted a within- and between-subjects design study in which two groups of 6- to 11-month-old infants were tested on two separate days. One group was currently feeding a milk-based formula whereas the other was feeding a protein hydrolysate formula, a particularly unpleasant tasting formula to adults that contains similar flavor notes (e.g., sulfur volatiles) with Brassica vegetables such as broccoli. In counterbalanced order, acceptance of pureed broccoli/cauliflower was determined during one test session and pureed carrots on the other. Although there were no group differences in the amount of carrots consumed, hydrolysate infants consumed significantly less broccoli/cauliflower relative to carrots when compared to those who were currently fed milk based formulas (F(1,72 df)=4.43; p=0.04). The mothers of hydrolysate infants were significantly more likely to report that their infants did not enjoy feeding the broccoli/cauliflower (54.2%) when compared to mothers of infants being fed milk-based formulas (28.0%; Chi-Square (1 df)=4.79; p=0.03). Such findings are consistent with prior research that demonstrated a sensory specific satiety following repeated exposure to a particular flavor in milk. We hypothesize that when infants are experiencing a flavor in milk or formula, in the short term, the preference that develops is specific to the context it is experienced in (e.g., milk). Over the longer term, the preference may generalize to other contexts such as solid foods. Hydrolysate infants were also significantly more likely to be judged by their mothers as being more active (F(1,69 df)=3.95; p=0.05) and hesitant (F(1,69 df)=6.55; p=0.01) when compared to those infants who were feeding milk-based formulas, a finding that further supports the hypothesis that mother-child dynamics surrounding early feeding impacts upon mothers' perception of their children's temperament.

Decreased regurgitation with a soy formula containing added soy fiber

The objective of this randomized study was to determine if fiber-supplemented soy formula reduced regurgitation in young infants. We compared regurgitation in 179 infants randomly assigned cow's milk-based (CM, 90) formula or soy formula with fiber (SF, 89). Initial daily incidence was similar (CM, 3.6; SF, 3.9 episodes), but significantly lower after 7 days on SF (CM, 3.4; SF, 2.3; p = 0.001). Less frequent regurgitation after 7 days on SF was sustained after 28 days (CM, 48%; SF, 31% of feedings; p = 0.001). Feeding SF effectively managed regurgitation while providing balanced nutrition without altering caloric distribution as occurs with adding rice cereal to formula.

Widespread use of soy-based formula without clinical indications

OBJECTIVES

In view of reports of the growing popularity of soy-based formula for infants, we examined soy consumption and its possible overuse during early infancy in central Israel.

METHODS

Mothers of 1,803 infants aged 2, 4, 6 and 12 months attending well-baby clinics participated in a telephone survey covering background data, rate, duration, and pattern of soy-based formula use and the reasons for its initiation. The reasons were grouped into those based on the recommendations of the medical personnel and those based on mothers' initiative, and evaluated according to infants' age at soy-based formula initiation (0 to 1, 2 to 4 and 5 to 12 months). The symptoms that prompted soy-based formula use were assessed quantitatively.

RESULTS

The rate of soy-based formula use was 10.4% at 2 months and 31.5% at 12 months (P<0.001); 70.6%+/- 2.7% of the infants were given soy for>6 months. Regardless of infants' age, the role of the mothers in the decision to use soy-based formula was greater than that of the medical personnel, and increased significantly with age (chi for trend=0.018). A suspicion of cow's milk allergy was responsible for only 10.9% (7/64) of all soy initiations in infants aged 5 to 12 months. In all ages, occasional symptoms, mainly diarrhea (33.3%) and colic (19.8%), were the leading cause for recommending soy-based formula by medical personnel, whereas the personal preference without clinical justification was the leading cause among mothers.

CONCLUSIONS

The use of soy-based formula in central Israel is extensive and continues for long periods, with rates far beyond clinical indications. Mothers play a greater role than medical personnel in the decision to initiate soy-based formula.

Infant feeding with soy formula milk: effects on the testis and on blood testosterone levels in marmoset monkeys during the period of neonatal testicular activity

BACKGROUND

This study has addressed concerns about possible effects of feeding human infants soy formula milk (SFM).

METHODS

This is a feeding study in marmosets, using a mainly co-twin design. From 4-5 until 35-45 days of age, co-twin males were fed by hand with either standard (cow) formula milk (SMA = controls) or with SFM for approximately 8 h each day (2 h at weekends) and intake related to bodyweight. Blood samples were collected at 18-20 and at 35-45 days of age in 13 sets of co-twins plus two non-twin males per group and, at the later age, seven sets of co-twins were killed and the testes and pituitary gland fixed for cell counts.

RESULTS

Weight gain and formula intake were similar in both feeding groups. SMA-fed males had mean testosterone levels of 2.8-3.1 ng/ml, typical of the "neonatal testosterone rise", whereas SFM-fed males exhibited consistently lower mean levels (1.2-2.6 ng/ml); paired comparison in SMA-and SFM-fed co-twins at day 35-45 revealed 53-70% lower levels in 11 of 13 co-twins fed with SFM (P = 0.004). Further evidence for suppression of testosterone levels in SFM-fed males came from comparison of the frequency of low testosterone levels (<0.5 ng/ml). In historical controls aged 35-45 days, two out of 22 values were <0.5 ng/ml, a similar frequency as found in control SMA-fed males (one out of 15 values <0.5 ng/ml). In contrast, 12 out of 15 values for SFM-fed males were <0.5 ng/ml (P < 0.001). There was no consistent relationship between SFM intake/g and testosterone levels. Paradoxically, the mean number of Leydig cells per testis was increased by 74% (P < 0.001) in co-twins fed SFM, when compared with their SMA-fed brothers, whereas no significant changes were found in numbers of Sertoli and germ cells. Because of the lack of gonadotrophin assays, the number of immunopositive LHbeta and FSHbeta cells in the pituitary gland, and their ratio, were determined but no consistent difference was found between SMA- and SFM-fed twins.

CONCLUSIONS

Based on the average isoflavone content of the SFM brand used, intake of isoflavones was estimated at 1.6-3.5 mg/kg/day in the SFM-fed marmosets which is 40-87% of that reported in 4 month human infants fed on a 100% SFM diet. It is therefore considered likely that similar, or larger, effects to those shown here in marmosets may occur in human male infants fed with SFM. Whether the changes described result in longer-term effects is under investigation.