Assessment of Mycotoxin Exposure in Breastfeeding Mothers with Celiac Disease

Longitudinal follow-up of zearalenone and deoxynivalenol mycotoxins in breast milk in the first five months of life

OBJECTIVES

There is a possibility for exposed lactating mammalians to transfer some contaminants to their milk. This study aimed to determine the levels and changes of Zearalenone (ZEN), Deoxynivalenol (DON) mycotoxins for the first five months in human milk.

METHODS

Voluntary lactating mothers having infants with gestational length ≥ 37 weeks were enrolled between August 2017 and June 2018 in Şanlıurfa. Mothers and infants with chronic health problems were not included in the study. Human milk samples were taken at three different times; on enrollment (Day 6-10, visit 1), between 4 and 6 weeks postpartum (visit 2), and between 14 and 19 weeks postpartum (visit 3). Mycotoxin levels in human milk were measured utilizing Helica brand commercial kit.

RESULTS

Nineteen voluntary mothers and their breastfed infants with three human milk samples completed the study. The mean ages of mothers and infant (± SD) were 27.4 (± 5.4) years and 7.6 (± 0.9) days on enrollment. Median levels of ZEN and DON in human milk samples were 0.39 and 16.7 ng/mL, respectively. None of the cases had a ZEN daily intake higher than 250 ng/kg bw per day. However, three fourth of the cases had DON intake higher than > 1000 ng/kg bw per day. When adjusted for infant weight for age and sex, both ZEN levels and daily intake were decreased progressively from visit 1 to visit 3 (p < 0.001). DON levels and daily intake at visit 2 were found to be significantly lower in samples of visit 3 than that taken in visit 2 (p = 0.004 and p < 0.001, respectively).

CONCLUSIONS

Breast milk monitoring study revealed that ZEN and DON mycotoxins were present in the mother-infant environment. Contamination levels changed during the lactation period.

Oestrogens and progesterone in human milk and their effects on infant health outcomes: A narrative review

Human milk (HM) is a complex biological system that contains a wide range of bioactive components including oestrogens and progesterone. Whilst maternal oestrogens and progesterone concentrations drop rapidly after birth, they remain detectable in HM across lactation. Phytoestrogens and mycoestrogens, which are produced by plants and fungi, are also present in HM and can interact with oestrogen receptors to interfere with normal hormone functions. Despite the potential impact of HM oestrogens and progesterone on the infant, limited research has addressed their impact on the growth and health of breastfed infants. Furthermore, it is important to comprehensively understand the factors that contribute to these hormone levels in HM, in order to establish effective intervention strategies. In this review, we have summarized the concentrations of naturally occurring oestrogens and progesterone in HM from both endogenous and exogenous sources and discussed both maternal factors impacting HM levels and relationships with infant growth.

Mycotoxins Exposure in Cabinda, Angola—A Pilot Biomonitoring Survey of Breastmilk

Breast milk is considered the ideal form of nutrition for newborns and infants. However, it can carry over contaminants, namely mycotoxins, with biological effects to which this population is particularly vulnerable. Human biomonitoring and surveillance programs are particularly scarce in low-income countries, where food security is a more urgent priority in comparison with food safety. This pilot survey aims to assess exposure of breastfed infants to aflatoxin M1 (AFM1), zearalenone (ZEN), and ochratoxin A (OTA) in Angola, and to evaluate the main socio-demographical and food consumption determinants of lactating mothers. All 37 breast milk samples analyzed are found to be contaminated with ZEN and OTA, although none are found contaminated with AFM1. Contamination levels are lower than previously reported for ZEN but higher in the case of OTA. A significant association between ZEN levels in breast milk and the consumption of cookies by the lactating mothers is found. As for OTA, higher levels are observed in the milk from mothers with younger infants, for which high estimated daily intake (EDI) is determined. As far as the authors are aware, this is the first survey of the occurrence of mycotoxins in breast milk in Angola, so further human biomonitoring works should follow, given that mycotoxins are a global health issue that directly impact the health of populations.

Detection of multimycotoxins in camel feed and milk samples and their comparison with the levels in cow milk

Camel milk has been considered as an important source of nutrients and is commercialized in many countries of the world including the Middle East. This study aimed to investigate the presence of mycotoxins in camel feed and milk samples in comparison with the cow milk. Fumonisins (FUM), ochratoxin A (OTA), and zearalenone (ZEN) were detected in 14%, 39%, and 39% of the tested camel feed samples, respectively. Among the tested camel feed samples, 8.3% and 5.6% were co-contaminated with OTA+FUM and FUM+ZEN, respectively. In the case of milk samples, 46.15% of camel and 63.63% of cow were found contaminated with aflatoxin M1 (AFM1). In total, 16.2% and 8.1% of the milk samples were simultaneously contaminated with two and three mycotoxins, respectively. Although the levels of individual mycotoxins in the camel feed and milk samples were within the European Union (EU) permissible limits, their co-occurrence may pose severe risk to human and animal health due to possible additive and/or synergistic toxicities.

Knowledge and Behavioral Habits to Reduce Mycotoxin Dietary Exposure at Household Level in a Cohort of German University Students

Mycotoxins pose a health concern for humans. Therefore, strategies at pre- and post-harvest and maximum levels for food have been implemented, aimed to minimize the risk of dietary exposure. Yet, consumers’ dietary habits and life style play a substantial role in overall exposure. The aim of this study was to investigate knowledge of mycotoxins and accordance to behavioral practices or habits that may affect the risk of mycotoxin dietary exposure at the household level or when food commodities are obtained from non-regulated trade markets. For this purpose, an online survey was applied to a university student cohort (n = 186). The survey consisted of 23 questions grouped in five categories: Socio-demographic and income data, general life style and habits, knowledge about mycotoxins, compliance with the “17 golden rules to prevent mycotoxin contamination” of the German Federal Institute for Risk Assessment (BfR), and measures towards reducing health risks. We paid particular attention to knowledge and compliance of a group acquiring food items in markets outside regulation and surveillance, namely, adherents of food movements such as food sharing or dumpster diving. The results of our study indicate a generally rather low level of knowledge about mycotoxins in the investigated cohort, as well as a weak perception of their associated risks compared to similar studies; around half of the cohort was unfamiliar with the term “mycotoxin” and the health risks of mycotoxins were considered comparable to those of pesticides, heavy metals, microplastics and food additives. We observed, in general, a relatively high degree of compliance with the proposed golden rules. The rules with the highest compliance related to deteriorated foods with visible signs of fungal infestation, probably because these are already considered as food waste. Rules that were less followed included those that require a specific knowledge of food storage and early fungal contamination stages, namely preventive measures related to storage of bread. Adherents of food movements did not differ significantly with the control group in terms of knowledge, risk perception and compliance with the 17 golden rules. This may be due to the homogeneity of the cohort in terms of demography, age and educational level. However, significant low compliance in the food movements group was observed with the rules “Buy fruit and vegetables that are as intact as possible, i.e., without injuries and bruises” and “Rotten fruit should neither be eaten nor further processed into compote or jam”, possibly because of ideological convictions around reducing food waste. In conclusion, mycotoxin prevention strategies should not end at the retail level; in particular, clarification and information regarding health risk from mycotoxins are suggested in order to reduce the risk of exposure in private households or in informal trade markets. The results of this study should, however, be interpreted with caution due to the specific characteristics of the cohort in terms of age and educational level and the disparity in size between the control and the food movement group. This study is a starting point for evaluating and understanding the consumer perspective on mycotoxins.

An Immunoenzymatic Method for the Determination of Ochratoxin A in Biological Liquids (Colostrum and Cow's Milk)

Ochratoxins are mycotoxins that have been extensively studied lately due to the multiple toxic effects such as nephrotoxicity, hepatotoxicity, and carcinogenicity. These toxins contaminate plant and animal foods and after ingestion they reach into body fluids. The method of competitive direct enzyme immunoassay, in the solid phase, was validated through the determination of specific parameters (performance, linearity, recovery percentage, limit of detection, limit of quantification). The validated method was used to determine ochratoxin A in colostrum and cow’s milk. The method applied for the determination of ochratoxin A was linear for the concentration range of 0.0–0.5 ng/mL, the value for the regression coefficient (r) was 0.9838. Ochratoxin A was present in 91.67% of the colostrum and in 93.33% of cow’s milk samples. The linearity of the method, demonstrated for very low concentrations of analyte, the detection limit as well as the limit of quantification recommend the method for the determinations of micro-pollutants from foods, including biological fluids.

S2k guidelines (consensus statement) for diagnosis and therapy of dermatitis herpetiformis initiated by the European Academy of Dermatology and Venereology (EADV)

INTRODUCTION

Dermatitis herpetiformis (DH) is a chronic, pruritic, gluten-induced skin disorder characterized by subepidermal granular IgA deposition and a variable degree of enteropathy identical to that seen in coeliac disease. So far, there has been no European consensus about the management of DH.

METHODS

The guidelines were created by small subgroups of a guideline committee consisting of 26 specialists from various medical fields and one patients' representative. The members of the committee then discussed the guidelines and voted for the final version at two consensus meetings. The guidelines were developed under the support of the European Academy of Dermatology and Venereology (EADV) and in collaboration with the European Dermatology Forum (EDF).

RESULTS

The guidelines summarize evidence-based and expert-based recommendations (S2 level) for the management of DH (see Appendix).

CONCLUSION

These guidelines will improve the quality of management of DH and support dermatologists in their diagnostic and therapeutic decisions.

Antioxidative Molecules in Human Milk and Environmental Contaminants

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

The Prevalence of Anti-Zein Antibodies: A Comparative Study between Celiac Disease and Irritable Bowel Syndrome

Celiac disease (CD) is a chronic immune-mediated enteropathy triggered by exposure to dietary gluten in genetically predisposed individuals. In contrast, irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder affecting the large intestine, without an autoimmune component. Here, we evaluated the prevalence of IgA and IgG antibodies to maize zeins (AZA) in patients with CD and IBS. Using an in-house ELISA assay, the IgA and IgG anti-zein antibodies in the serum of 37 newly diagnosed CD (16 biopsy proved and 21 serological diagnosis) and 375 IBS patients or 302 healthy control (HC) subjects were measured. Elevated levels of IgA AZA were found in CD patients compared with IBS patients (p < 0.01) and HC (p < 0.05). CD patients had the highest prevalence (35.1%), followed by IBS (4.3%) and HCs (2.3%) (p < 0.0001). IgG AZA antibodies were not found in any CD patients, IBS patients, or HC subjects. A significant positive correlation was found between IgA AZA with IgA anti-gliadin (AGA, r = 0.34, p < 0.01) and IgA anti-deaminated gliadin peptides (DGP, r = 0.42, p < 0.001) in the celiac disease group. Taken together, our results show for the first time a higher prevalence of AZA IgA antibodies in newly diagnosed CD patients than in IBS patients, confirming a biased immune response to other gliadin-related prolamins such as maize zeins in genetically susceptible individuals.

Zearalenone and Its Metabolites-General Overview, Occurrence, and Toxicity

Mycotoxins are secondary metabolites of filamentous fungi and represent one of the most common groups of food contaminants with low molecular weight. These toxins are considered common and can affect the food chain at various stages of production, harvesting, storage and processing. Zearalenone is one of over 400 detected mycotoxins and produced by fungi of the genus Fusarium; it mainly has estrogenic effects on various organisms. Contaminated products can lead to huge economic losses and pose risks to animals and humans. In this review, we systemize information on zearalenone and its major metabolites.

Risk assessment of ochratoxin A in food

The European Commission asked EFSA to update their 2006 opinion on ochratoxin A (OTA) in food. OTA is produced by fungi of the genus Aspergillus and Penicillium and found as a contaminant in various foods. OTA causes kidney toxicity in different animal species and kidney tumours in rodents. OTA is genotoxic both in vitro and in vivo; however, the mechanisms of genotoxicity are unclear. Direct and indirect genotoxic and non-genotoxic modes of action might each contribute to tumour formation. Since recent studies have raised uncertainty regarding the mode of action for kidney carcinogenicity, it is inappropriate to establish a health-based guidance value (HBGV) and a margin of exposure (MOE) approach was applied. For the characterisation of non-neoplastic effects, a BMDL 10 of 4.73 μg/kg body weight (bw) per day was calculated from kidney lesions observed in pigs. For characterisation of neoplastic effects, a BMDL 10 of 14.5 μg/kg bw per day was calculated from kidney tumours seen in rats. The estimation of chronic dietary exposure resulted in mean and 95th percentile levels ranging from 0.6 to 17.8 and from 2.4 to 51.7 ng/kg bw per day, respectively. Median OTA exposures in breastfed infants ranged from 1.7 to 2.6 ng/kg bw per day, 95th percentile exposures from 5.6 to 8.5 ng/kg bw per day in average/high breast milk consuming infants, respectively. Comparison of exposures with the BMDL 10 based on the non-neoplastic endpoint resulted in MOEs of more than 200 in most consumer groups, indicating a low health concern with the exception of MOEs for high consumers in the younger age groups, indicating a possible health concern. When compared with the BMDL 10 based on the neoplastic endpoint, MOEs were lower than 10,000 for almost all exposure scenarios, including breastfed infants. This would indicate a possible health concern if genotoxicity is direct. Uncertainty in this assessment is high and risk may be overestimated.

Risk assessment of aflatoxins in food

EFSA was asked to deliver a scientific opinion on the risks to public health related to the presence of aflatoxins in food. The risk assessment was confined to aflatoxin B1 (AFB1), AFB2, AFG1, AFG2 and AFM1. More than 200,000 analytical results on the occurrence of aflatoxins were used in the evaluation. Grains and grain-based products made the largest contribution to the mean chronic dietary exposure to AFB1 in all age classes, while 'liquid milk' and 'fermented milk products' were the main contributors to the AFM1 mean exposure. Aflatoxins are genotoxic and AFB1 can cause hepatocellular carcinomas (HCCs) in humans. The CONTAM Panel selected a benchmark dose lower confidence limit (BMDL) for a benchmark response of 10% of 0.4 μg/kg body weight (bw) per day for the incidence of HCC in male rats following AFB1 exposure to be used in a margin of exposure (MOE) approach. The calculation of a BMDL from the human data was not appropriate; instead, the cancer potencies estimated by the Joint FAO/WHO Expert Committee on Food Additives in 2016 were used. For AFM1, a potency factor of 0.1 relative to AFB1 was used. For AFG1, AFB2 and AFG2, the in vivo data are not sufficient to derive potency factors and equal potency to AFB1 was assumed as in previous assessments. MOE values for AFB1 exposure ranged from 5,000 to 29 and for AFM1 from 100,000 to 508. The calculated MOEs are below 10,000 for AFB1 and also for AFM1 where some surveys, particularly for the younger age groups, have an MOE below 10,000. This raises a health concern. The estimated cancer risks in humans following exposure to AFB1 and AFM1 are in-line with the conclusion drawn from the MOEs. The conclusions also apply to the combined exposure to all five aflatoxins.

Aspergillus flavus and Fusarium verticillioides Interaction: Modeling the Impact on Mycotoxin Production

The influence of climate change on agricultural systems has been generally accepted as having a considerable impact on food security and safety. It is believed that the occurrence of mycotoxins will be greatly affected by future climate scenarios and this has been confirmed by recent data. Temperature (T) and CO2 increases, variation in rain intensity and distribution, as well as extreme weather events, affect the dominant fungal species in different ways, depending on their ecological needs. Therefore, the aim of this work was to study Aspergillus flavus (Af) and Fusarium verticillioides (Fv) co-occurrence in vitro in order to collect quantitative data on the effect of fungal interaction on growth and mycotoxin production and develop functions for their description. Experimental trials were organized with the cited fungi grown alone or together. They were incubated at different T regimes (10-40°C, step 5°C) for 21 days. Fungal growth was measured weekly, while AFs and FBs were quantified at the end of the incubation period. Temperature and incubation time significantly affected fungal growth both for Af and Fv (p ≤ 0.01), and a significant interaction between T and the presence of one versus both fungi influenced the amount of AFs and FBs produced. Each fungus was affected by the presence of the other fungus; in particular, Af and Fv showed a decrease in colony diameter of 10 and 44%, respectively, when they were grown together, compared to alone. The same influence was not found for mycotoxin production. In fact, the dynamics of toxin production in different temperature regimes followed a comparable trend with fungi grown alone or together, but a significant impact of inoculum × temperature interaction was highlighted. Fungal growth and toxin production in different T regimes were well described, both for AFs and FBs, by a Bete function. These results are the first attempt to model mycotoxigenic fungal co-occurrence under several T regimes; this is essential in order to improve effective prediction of growth and mycotoxin production by such fungi.

Occurrence of Aflatoxin M1 in Raw Milk Marketed in Italy: Exposure Assessment and Risk Characterization

The current study is based on the AFM₁ contamination of milk determined from April 2013 to December 2018 in the framework of a self-control plan of six milk processing plants in Italy. These data – together with the consumption data of milk consumers – were evaluated and used for the calculation of the Estimated Daily Intake (EDI), the Hazard Index (HI), and the fraction of hepatocarcinoma cases (HCC) due to AFM₁ exposure in different population groups. Altogether a total of 31,702 milk samples were analyzed, representing 556,413 tons of milk, which is an outstanding amount compared to published studies. The results indicate the monthly fluctuation of AFM₁ levels through a period of nearly 6 years. The EDI of AFM₁ in different population groups was in the range of 0.025–0.328 ng kg⁻¹ body weight (bw) per day, based on the average consumption levels and weighted mean contamination of the milk in the study period. Considering average consumptions, in the groups of infants and toddlers, the HI calculation resulted in 1.64 and 1.4, respectively, while for older age groups, it was <1. The estimated fractions of HCC incidences attributable to the AFM₁ intakes were 0.005 and 0.004 cases per 100,000 individuals in the 0–0.9 and 1–2.9-year age groups, respectively, and below 0.004 cases in the other age categories. The monthly average AFM₁ contamination of tested milk consignments ranged between 7.19 and 22.53 ng kg⁻¹. Although the results of this extensive investigation showed a low risk of HCC, the variability of climatic conditions throughout years that influence AFB₁ contamination of feed and consequently AFM₁ contamination of milk justifies their continuous monitoring and update of the risk assessment.

Human milk mycotoxin contamination: smoking exposure and breastfeeding problems

Purpose: Mammalian milk may contain pollutants as a result of the maternal exposure. The objective was to determine the presence of selected mycotoxins in human milk and to investigate the effect of maternal characteristics on breastmilk mycotoxin levels and to examine the effect of mycotoxin contamination on lactational problems.Materials and methods: Information about maternal characteristics were taken by a questionnaire and breast milk samples were collected. Levels of aflatoxins M1 (AFM1), ochratoxins A (OTA), zearalenone (ZEN), Deoxynivalenol (DON) were determined by the solid-phase direct competitive enzyme immunoassay.Results: Median levels of breast milk AFM1 and OTA was 3.07 pg/mL and 1.38 ng/mL, respectively. ZEN and DON levels were higher than 0.3 ng/mL in 59% and higher than 10 ng/mL in 37.7%. After controlling for confounding factors, mothers who experienced "delayed onset of lactogenesis" had odds 3.33 times more for the highest quartile of ZEN and mothers with cracked nipples had odds 8.36 times more for the highest quartile of DON. Multiple regression analysis revealed that smoking exposure (environmental, maternal smoking versus never) significantly affected being in the highest quartile of OTA.Conclusion: Mycotoxin can pass to breast milk and smoking exposure of the mother may influence this situation. Mycotoxin exposure may lead to lactation problems. Maternal and infant health can be protected by preventing smoking exposure.