Working with companies that manufacture breastmilk substitutes: An EAACI position paper

Breastmilk is the optimal source of nutrition for infants and should ideally be provided exclusively for the first 6 months of life, and alongside complementary food until 2 years of life. However, there are circumstances where a breastmilk substitute (BMS) may be required. This includes maternal and/or child conditions or personal preference. Whilst these circumstances should never be used as an opportunity to promote BMS, healthcare professionals (HCPs) need to have the knowledge of suitable alternatives and should always be guided by scientific and health motives when recommending a BMS. The Task Force 'Milk Formula Industry Sponsorship' from the European Academy of Allergy and Clinical Immunology (EAACI), provides with this publication recommendations for EAACI interactions with the BMS manufacturers and how this will be supervised.

An economic analysis of human milk supplementation for very low birth weight babies in the USA

BACKGROUND

An exclusive human milk diet (EHMD) using human milk based products (pre-term formula and fortifiers) has been shown to lead to significant clinical benefits for very low birth weight (VLBW) babies (below 1250 g). This is expensive relative to diets that include cow's milk based products, but preliminary economic analyses have shown that the costs are more than offset by a reduction in the cost of neonatal care. However, these economic analyses have not completely assessed the economic implications of EHMD feeding, as they have not considered the range of outcomes affected by it.

METHODS

We conducted an economic analysis of EHMD compared to usual practice of care amongst VLBW babies in the US, which is to include cow's milk based products when required. Costs were evaluated from the perspective of the health care payer, with societal costs considered in sensitivity analyses.

RESULTS

An EHMD substantially reduces mortality and improves other health outcomes, as well as generating substantial cost savings of $16,309 per infant by reducing adverse clinical events. Cost savings increase to $117,239 per infant when wider societal costs are included.

CONCLUSIONS

An EHMD is dominant in cost-effectiveness terms, that is it is both cost-saving and clinically beneficial, for VLBW babies in a US-based setting.

Cost-effectiveness analysis of infant feeding modalities for virally suppressed mothers in Canada living with HIV

OBJECTIVE

The aim of the study was to determine whether exclusive breastfeeding or exclusive formula feeding is more cost-effective when a Canadian mother with HIV is adherent to antiretroviral therapy and has full virologic suppression.

DESIGN

Current Canadian guidelines recommend that mothers with HIV practice exclusive formula feeding. This contradicts the updated World Health Organization (WHO) guidelines which recommend that mothers with HIV should breastfeed for ≥12 months while receiving support for antiretroviral therapy adherence. Due to the economic and health risks and benefits associated with each modality, there remains expert disagreement on whether the WHO recommendations should be adopted in high-income countries.

METHODS

A microsimulation model was developed to estimate lifetime costs and effectiveness (i.e., infant's quality-adjusted life years) of a hypothetical group of 1,000,000 initially healthy, HIV-negative infants, if the mother with HIV was on antiretroviral therapy with full virologic suppression and either exclusive breastfeeding or exclusive formula feeding. The model was developed from the economic perspective of the Ontario Ministry of Health, taking into account direct costs associated with infant feeding modality as well as related indirect costs born out of the child's lifetime health outcomes. Uncertainties related to model parameters were evaluated using one-way and probabilistic sensitivity analyses.

RESULTS

In comparison to exclusive formula feeding, exclusive breastfeeding was the dominant feeding modality (i.e., less costly and more effective) yielding cost-savings of $13,812 per additional quality-adjusted life year gained. Neither one-way nor probabilistic sensitivity analyses altered the conclusions.

CONCLUSIONS

Despite the risk of HIV transmission, exclusive breastfeeding was more cost-effective than exclusive formula feeding. These findings merit review of current infant feeding guidelines for mothers with HIV living in high-income countries.

Federal Regulation of Infant and Toddler Food and Drink Marketing and Labeling

Foods and beverages marketed for infants, babies, and toddlers through 3 years of age is a $7 billion industry in the United States, incorporating a wide range of products, including infant formula and other types of drinks, foods, and snacks. The World Health Organization (“WHO”) found that mothers “are often inundated with incorrect and biased information” from direct advertising, health claims on products, information packs from sales representatives, and the distribution of samples of infant formula and “educational materials” by infant formula manufacturers. To address these problematic practices, in 1981, the WHO established the International Code of Marketing of Breast-milk Substitutes (the “Code”) to end the inappropriate marketing of infant formula and other food and drinks intended for children up to age two. In 2016, WHO expanded the definition of breastmilk substitutes to include milk and milk products specifically marketed for feeding infants and young children up to age three. However, the United States is one of a minority of countries that has not passed any legislation or regulation to implement the Code. Furthermore, U.S. regulation and enforcement actions have not kept pace with the introduction of new products and product categories and the profusion of labeling and marketing claims questionably implying nutritional and developmental benefits from these products.

Cost-effectiveness of using an extensively hydrolyzed casein formula containing Lactobacillus rhamnosus GG in managing infants with cow's milk allergy in the US

OBJECTIVE

To estimate the cost-effectiveness of using an extensively hydrolyzed casein formula containing the probiotic Lactobacillus rhamnosus GG (eHCF + LGG; Nutramigen LGG) compared with an eHCF alone and an amino acid formula (AAF) in treating cow's milk allergy (CMA) in the US, from the perspective of third-party insurers and from parents.

METHODS

A decision model was used to estimate the probability of cow's milk allergic infants developing tolerance to cow's milk by 18 months. The model also estimated the cost to insurers and parents (US dollars at 2016 prices) of managing infants over 18 months after starting one of the formulae, as well as the relative cost-effectiveness of each of the formulae.

RESULTS

The probability of developing tolerance to cow's milk was higher among infants who were fed eHCF + LGG compared with those fed an eHCF alone or an AAF. Infants who are initially fed with eHCF + LGG are expected to utilize fewer healthcare resources than those fed with one of the other formulae. Hence, the estimated total healthcare cost incurred by third-party insurers and parents of initially feeding infants with eHCF + LGG was less than that of feeding infants with an eHCF alone or an AAF.

CONCLUSION

Initial management of newly-diagnosed cow's milk allergic infants with eHCF + LGG was found to afford a cost-effective strategy to both third-party insurers and parents when compared to an eHCF alone or an AAF.

Expert panel on practice patterns in the management of cow's milk protein allergy and associated economic burden of disease on health service in Turkey

AIMS

To evaluate practice patterns in the management of cow's milk protein allergy (CMPA) and associated economic burden of disease on health service in Turkey.

MATERIALS AND METHODS

This study was based on experts' views on the practice patterns in management of CMPA manifesting with either proctocolitis or eczema symptoms and, thereby, aimed to estimate economic burden of CMPA. Practice patterns were determined via patient flow charts developed by experts using the modified Delphi method for CMPA presented with proctocolitis and eczema. Per patient total 2-year direct medical costs were calculated, including cost items of physician visits, laboratory tests, and treatment.

RESULTS

According to the consensus opinion of experts, 2-year total direct medical cost from a payer perspective and societal perspective was calculated to be $US2,116.05 and $US2,435.84, respectively, in an infant with CMPA presenting with proctocolitis symptoms, and $US4,001.65 and $US4,828.90, respectively, in an infant with CMPA presenting with eczema symptoms. Clinical nutrition was the primary cost driver that accounted for 89-92% of 2-year total direct medical costs, while the highest total direct medical cost estimated from a payer perspective and societal perspective was noted for the management of an exclusively formula-fed infant presenting either with proctocolitis ($US3,743.85 and $US4,025.63, respectively) or eczema ($US6,854.10 and $US7,917.30, respectively). The first line use of amino acid based formula (AAF) was associated with total direct cost increment $US1,848.08 and $US3,444.52 in the case of proctocolitis and eczema, respectively.

LIMITATIONS

Certain limitations to this study should be considered. First, being focused only on direct costs, the lack of data on indirect costs or intangible costs of illness seems to be a major limitation of the present study, which likely results in a downward bias in the estimates of the economic cost of CMPA. Second, given the limited number of studies concerning epidemiology and practice patterns in CMPA in Turkey, use of expert clinical opinion of the panel members rather than real-life data on practice patterns that were used to identify direct medical costs might raise a concern with the validity and reliability of the data. Also, while this was a three-step study with six experts included in the first stage (developing local guidelines for diagnosis, treatment, and follow-up of infants with CMPA in Turkey) and 410 pediatricians included in the second stage (a cross-sectional questionnaire-survey to determine pediatricians' awareness and practice of CMPA in infants and children), only four members were included in the present Delphi panel, which allows a limited discussion. Third, lack of sensitivity analyses and exclusion of indirect costs and costs related to alterations in quality of life, behavior of infants, and general well-being of infants and their parents from the cost-analysis seems to be another limitation that may have caused under-estimation of relative cost-effectiveness of the formulae. Fourth, calculation of costs per local guidelines rather than real-life practice patterns is another limitation that, otherwise, would extend the knowledge achieved in the current study. Notwithstanding these limitations, the present expert panel provided practice patterns in the management of CMPA and an estimate of the associated costs, depending on the symptom profile at initial admission for the first time in Turkey.

CONCLUSIONS

In conclusion, in providing the first health economic data on CMPA in Turkey, the findings revealed that CMPA imposes a substantial burden on the Turkish healthcare system from both a payer perspective and societal perspective, and indicated clinical nutrition as a primary cost driver. Management of infants presenting with eczema, exclusively formula-fed infants, and first line use of AAF were associated with higher estimates for 2-year direct medical costs.

Surveillance and molecular typing of Cronobacter spp. in commercial powdered infant formula and follow-up formula from 2011 to 2013 in Shandong Province, China

BACKGROUND

Infection with Cronobacter spp. leads to neonatal meningitis, necrotizing enterocolitis and bacteremia. Cronobacter spp. are reported to comprise an important pathogen contaminating powdered infant formula (PIF) and follow-up formula (FUF), although little is known about the contamination level of Cronobacter spp. in PIFs and FUFs in China.

RESULTS

In total, 1032 samples were collected between 2011 and 2013. Forty-two samples were positive, including 1.6% in PIFs and 6.5% in FUFs. The strains were susceptible to most antibiotics except for cefoxitin. Pulsed-field gel electrophoresis after XbaI digestion produced a total of 36 banding patterns. The 38 strains were found in 27 sequence types (STs), of which nine types (ST454 to ST462) had not been reported in other countries. The clinically relevant strains obtained from the 38 isolates in the present study comprised three ST3, two ST4, two ST8 and one ST1.

CONCLUSION

The contamination rate in the PIF and FUF has stayed at a relatively high level. The contamination rate of PIF was significantly lower than FUF. The isolates had high susceptibility to the antibiotics tested, except cefoxitin. There were polymorphisms between the Cronobacter spp. as indicated by pulsed-field gel electrophoresis and multilocus sequence typing. Therefore, contamination with Cronobacter spp. remains a current issue for commercial infant formulas in China. © 2016 Society of Chemical Industry.

Impact of Optimized Breastfeeding on the Costs of Necrotizing Enterocolitis in Extremely Low Birthweight Infants

OBJECTIVE

To estimate risk of necrotizing enterocolitis (NEC) for extremely low birth weight (ELBW) infants as a function of preterm formula (PF) and maternal milk intake and calculate the impact of suboptimal feeding on the incidence and costs of NEC.

STUDY DESIGN

We used aORs derived from the Glutamine Trial to perform Monte Carlo simulation of a cohort of ELBW infants under current suboptimal feeding practices, compared with a theoretical cohort in which 90% of infants received at least 98% human milk.

RESULTS

NEC incidence among infants receiving ≥98% human milk was 1.3%; 11.1% among infants fed only PF; and 8.2% among infants fed a mixed diet (P = .002). In adjusted models, compared with infants fed predominantly human milk, we found an increased risk of NEC associated with exclusive PF (aOR = 12.1, 95% CI 1.5, 94.2), or a mixed diet (aOR 8.7, 95% CI 1.2-65.2). In Monte Carlo simulation, current feeding of ELBW infants was associated with 928 excess NEC cases and 121 excess deaths annually, compared with a model in which 90% of infants received ≥98% human milk. These models estimated an annual cost of suboptimal feeding of ELBW infants of $27.1 million (CI $24 million, $30.4 million) in direct medical costs, $563 655 (CI $476 191, $599 069) in indirect nonmedical costs, and $1.5 billion (CI $1.3 billion, $1.6 billion) in cost attributable to premature death.

CONCLUSIONS

Among ELBW infants, not being fed predominantly human milk is associated with an increased risk of NEC. Efforts to support milk production by mothers of ELBW infants may prevent infant deaths and reduce costs.

Infant and young child feeding practices among children under 2 years of age and maternal exposure to infant and young child feeding messages and promotions in Dar es Salaam, Tanzania

There are limited data describing infant and young child feeding practices (IYCF) in urban Tanzania. This study assessed the types of foods consumed by children under 2 years of age and maternal exposure to promotions of these foods in Dar es Salaam, Tanzania. A cross-sectional survey was conducted among 305 mothers of children less than 24 months of age who attended child health services in October and November, 2014. Among infants less than 6 months of age, rates of exclusive breastfeeding were low (40.8%) and a high proportion (38.2%) received semi-solid foods. Continued breastfeeding among 20-23-month-olds was only 33.3%. Consumption of breastmilk substitutes was not prevalent, and only 3.9% of infants less than 6 months of age and 4.8% of 6-23 month-olds were fed formula. Among 6-23-month-olds, only 38.4% consumed a minimum acceptable diet (using a modified definition). The homemade complementary foods consumed by the majority of 6-23-month-olds (85.2%) were cereal-dominated and infrequently contained micronutrient-rich ingredients. Only 3.1% of 6-23-month-olds consumed commercially produced infant cereal on the day preceding the interview. In contrast, commercially produced snack foods were consumed by 23.1% of 6-23-month-olds. Maternal exposure to commercial promotions of breastmilk substitutes and commercially produced complementary foods was low (10.5% and 1.0%, respectively), while exposure to promotions of commercially produced snack foods was high (45.9%). Strategies are needed to improve IYCF practices, particularly with regard to exclusive and continued breastfeeding, increased dietary diversity and consumption of micronutrient-rich foods, and avoidance of feeding commercially produced snack foods.

Considerations in developing lipid-based nutrient supplements for prevention of undernutrition: experience from the International Lipid-Based Nutrient Supplements (iLiNS) Project

The International Lipid-Based Nutrient Supplements (iLiNS) Project began in 2009 with the goal of contributing to the evidence base regarding the potential of lipid-based nutrient supplements (LNS) to prevent undernutrition in vulnerable populations. The first project objective was the development of acceptable LNS products for infants 6-24 months and for pregnant and lactating women, for use in studies in three countries (Burkina Faso, Ghana and Malawi). This paper shares the rationale for a series of decisions in supplement formulation and design, including those related to ration size, ingredients, nutrient content, safety and quality, and packaging. Most iLiNS supplements have a daily ration size of 20 g and are intended for home fortification of local diets. For infants, this ration size is designed to avoid displacement of breast milk and to allow for dietary diversity including any locally available and accessible nutrient-dense foods. Selection of ingredients depends on acceptability of flavour, micronutrient, anti-nutrient and essential fatty acid contents. The nutrient content of LNS designed to prevent undernutrition reflects the likelihood that in many resource-poor settings, diets of the most nutritionally vulnerable individuals (infants, young children, and pregnant and lactating women) are likely to be deficient in multiple micronutrients and, possibly, in essential fatty acids. During ingredient procurement and LNS production, safety and quality control procedures are required to prevent contamination with toxins or pathogens and to ensure that the product remains stable and palatable over time. Packaging design decisions must include consideration of product protection, stability, convenience and portion control.

Cost-effectiveness of partially hydrolyzed whey protein formula in the primary prevention of atopic dermatitis in high-risk urban infants in Southeast Asia

BACKGROUND

Atopic dermatitis (AD) is one of the most common skin conditions among infants. Proteins found in cow's milk formula (CMF) have been found to be attributable to heightened AD risk, particularly in infants with familial AD heredity. Previous studies have suggested that intervention with partially hydrolyzed formula in nonexclusively breastfed infants can have a protective effect against AD development.

OBJECTIVE

The aim of the present study was to compare the estimates of the economic impact of reducing the AD incidence by feeding a partially hydrolyzed whey-based formula (PHF-W) instead of a standard CMF to high-risk nonexclusively breastfed urban infants for the first 17 weeks of life in the Philippines, Malaysia, and Singapore.

METHODS

In each country, a mathematical model simulated AD incidence and burden from birth to 6 years of age of using PHF-W versus CMF in the target population using data from the German Infant Nutritional Intervention study. The models integrated literature, current cost and market data, and expert clinician opinion. Modeled outcomes included AD risk reduction, time spent after AD diagnosis, AD symptom-free days, quality-adjusted life years (QALYs), and costs (direct and indirect). Outcomes were discounted at 3% per year. Costs were expressed in USD.

RESULTS

Feeding high-risk infants PHF-W instead of CMF resulted in an estimated absolute 14% (95% CI 1-24) AD risk reduction, a 0.69-year (95% CI 0.25-1.13) reduction in the time spent after AD diagnosis per child, reductions of 16-38 AD days, and gains in 0.02-0.04 QALYs, depending on the country. The per-child AD-related 6-year cost-saving estimates of feeding high-risk infants with PHF-W versus CMF were USD 739 in Singapore, USD 372 in Malaysia, and USD 237 in the Philippines.

Increasing breastfeeding in WIC participants: cost of formula as a motivator

OBJECTIVE

To assess the cost of infant formula, explore mothers' perceptions of formula cost, and assess whether cost influences the decision to breastfeed.

METHODS

A mixed-methodological descriptive study with survey (phase 1) and interviews (phase 2) was completed in Rhode Island Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) offices. Thirty non-breastfeeding mothers participated in phase 1 and 14 pregnant women participated in phase 2. Means and frequencies were calculated for phase 1. For phase 2, data were organized into matrices and thematic analysis identified key themes.

RESULTS

Non-breastfeeding mothers were spending an extra $46 a month on average in their child's fourth month on formula beyond the formula supplied by WIC. This was perceived as high, but formula cost did not influence their decision to breastfeed. For mothers intending to breastfeed, cost information was perceived as an additional motivation.

CONCLUSIONS AND IMPLICATIONS

Information on supplemental formula cost could be provided as a motivator for women intending to breastfeed. Future research should investigate how cost information could be used to support breastfeeding initiation and duration among WIC mothers.

Isolation and identification of antioxidant peptides from commercial soybean-based infant formulas

Soybean-based infant formulas (SBIFs) based on soybean protein isolate (90% of proteins) are an interesting alternative to cow's milk infant formulas. Different works have demonstrated the presence of bioactive peptides in different soybean-based foodstuffs. The aim of this work was the evaluation, for the first time, of antioxidant peptides in five different commercially available SBIFs. Ultrafiltration through 10 kDa molecular weight cut-off filters was the most suitable extraction method. Despite peptide concentrations ranging between 1.19 and 2.27 mg/mL, similar antioxidant capacities were detected in all SBIF extracts. Extracts were further fractionated according to their molecular weight by ultrafiltration, and fractions from 5 to 10 kDa, 3 to 5 kDa, and below 3 kDa were obtained. The most active fraction was further fractionated by off-gel isoelectrofocusing and reversed-phase chromatography. Antioxidant fractions were also submitted to simulated gastrointestinal digestion (GI) with pepsin and pancreatin to evaluate their antioxidant capacity after digestion. Peptides were identified by HPLC-ESI-Q-ToF-MS/MS. At least 120 peptides were identified in every antioxidant fraction, with 42 peptides common to all SBIFs.

The cost-savings of implementing kangaroo mother care in Nicaragua

OBJECTIVE

To examine the costs of implementing kangaroo mother care (KMC) in a referral hospital in Nicaragua, including training, implementation, and ongoing operating costs, and to estimate the economic impact on the Nicaraguan health system if KMC were implemented in other maternity hospitals in the country.

METHODS

After receiving clinical training in KMC, the implementation team trained their colleagues, wrote guidelines for clinicians and education material for parents, and ensured adherence to the new guidelines. The intervention began September 2010 The study compared data on infant weight, medication use, formula consumption, incubator use, and hospitalization for six months before and after implementation. Cost data were collected from accounting records of the implementers and health ministry formularies.

RESULTS

A total of 46 randomly selected infants before implementation were compared to 52 after implementation. Controlling for confounders, neonates after implementation had lower lengths of hospitalization by 4.64 days (P = 0.017) and 71% were exclusively breastfed (P < 0.001). The intervention cost US$ 23 113 but the money saved with shorter hospitalization, elimination of incubator use, and lower antibiotic and infant formula costs made up for this expense in 1 - 2 months. Extending KMC to 12 other facilities in Nicaragua is projected to save approximately US$ 166 000 (based on the referral hospital incubator use estimate) or US$ 233 000 after one year (based on the more conservative incubator use estimate).

CONCLUSIONS

Treating premature and low-birth-weight infants in Nicaragua with KMC implemented as a quality improvement program saves money within a short period even without considering the beneficial health effects of KMC. Implementation in more facilities is strongly recommended.

WIC (The Special Supplemental Nutrition Program for Women, Infants, and Children): policy versus practice regarding breastfeeding

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides foods, education, and referrals to participants who are considered to be at nutritional risk. The outreach of the program is impressive, and nearly 9.17 million people participated in the program in 2010. WIC participation is associated with many positive outcomes, including improved birthweights and childhood dietary practices. Despite these benefits, WIC mothers experience lower breastfeeding rates when compared with demographically similar women who do not participate in the WIC program. According to WIC, "A breastfeeding mother and her infant shall be placed in the highest priority level." Despite this statement and others that support breastfeeding, WIC allocates only 0.6% of its budget toward breastfeeding initiatives. Formula expenses accounted for 11.6% ($850 million) of WIC's 2009 expenses. The inconsistency between WIC's policies that encourage breastfeeding vs. practices that favor formula begs further examination. Research shows consistent success with peer counseling programs among WIC participants; however, little money is budgeted for these programs. Rebates included, WIC spends 25 times more on formula than on breastfeeding initiatives. The American Academy of Nursing Expert Panel on Breastfeeding is calling for a re-evaluation of how these taxpayer dollars are spent. Additionally, the American Academy of Nursing recommends a shift from formula bargaining to an investment in structured peer counseling programs. All WIC programs should offer peer counseling support services that encourage breastfeeding and meet the needs of the families they serve.

The economic burden of infant formula on families with young children in the Philippines

BACKGROUND

Infant formula usage places children at risk for illness and death. Studies in the United States demonstrated high economic burden, health care costs, and absenteeism of caregivers associated with formula usage. Despite high formula usage in developing countries, no economic studies were found. This study examines the financial burden of purchasing infant formula and increased health care expenditure in the Philippines, a developing country with a per capita income of $3930. The average exchange rate of the peso to the US dollar for 2003 was $1 to P52, according to Bangko Sentral ng Pilipinas (BSP).

METHODS

This is a secondary analysis of the 2003 Family Income and Expenditure Survey, a national cross-sectional multistage cluster survey of 42 094 households.

RESULTS

Almost half of Philippine families with a young child and one-third of families living on less than $2 per day purchase formula. Nationally, $260 million was spent on infant formula in 2003. Formula-buying families with young children had spent an aggregate of $143.9 million on medical care compared to $56.6 million by non-formula-buying families. After adjusting for income and nonmilk family expenditures, the average formula-purchasing Philippine family spent an additional $0.30 (95% CI: 0.24 - 0.36; r(2) = 0.08) on medical expenditure for every $1 spent on formula.

CONCLUSIONS

The economic burden from infant formula purchase and out-of-pocket medical expenditure exceeded $400 million in 2003. This cost was aside from other costs, such as absenteeism and the risk of childhood death and illness. These expenses caused an unnecessary burden on Filipino families and could instead have been invested in education and other social services.

Cost-effectiveness of using an extensively hydrolysed formula compared to an amino acid formula as first-line treatment for cow milk allergy in the UK

OBJECTIVE

  To estimate the cost-effectiveness of using an extensively hydrolysed formula (eHF; Nutramigen) compared with an amino acid formula (AAF; Neocate) as first-line treatment for cow milk allergy (CMA) in the UK, from the perspective of the National Health Service (NHS).

METHOD

  A decision model was constructed depicting the treatment paths and associated resource use attributable to first-line management of CMA with the two formulae. The model was based on the case records of 145 AAF-treated infants and 150 matched eHF-treated patients from The Health Improvement Network (THIN) database [a nationally representative database of patients registered with general practitioners (GPs) in the UK]. The model estimated the costs and consequences of patient management over 12 months following their initial GP visit for CMA.

RESULTS

  Patients presenting with a combination of gastrointestinal symptoms and eczema accounted for 44% of all patients in both groups. Those with gastrointestinal symptoms alone and eczema alone accounted for up to a further 39% and 13%, respectively. Those with urticaria and faltering growth accounted for <5% and ≤6% of all patients, respectively. Patients' age and weight at presentation was a mean 2.6-2.8 months and 4.4 kg, respectively. It took a mean 2.2 months to start a formula after initially seeing a GP. Time to symptom resolution following the start of treatment was 1.2 months in both groups; hence, the mean number of symptom-free months during the 12 months following the initial GP visit was estimated to be 8.6 months in both groups. Patients treated with an eHF had a mean 13.1 GP visits over the 12 months compared to 17.5 visits made by AAF-treated patients (p < 0.001). The NHS cost of managing a CMA infant over the first 12 months following initial presentation to a GP was estimated to be £1853 and £3161 for an eHF-treated and AAF-treated patient, respectively.

CONCLUSION

  Starting treatment for CMA with an eHF was the cost-effective option, as there were no significant differences in clinical outcomes between the two groups. A prospective, randomized controlled trial would allow a definitive confirmation of these findings.

Economic evaluation of a 100% whey-based partially hydrolyzed infant formula in the prevention of atopic dermatitis among Swiss children

OBJECTIVE

A pharmacoeconomic analysis was undertaken to determine costs, consequences, and cost-effectiveness of a partially hydrolyzed 100% whey-based infant formula, NAN-HA®, manufactured by Nestlé S.A, Switzerland (PHF-W), branded under BEBA HA® in Switzerland, in the prevention of atopic dermatitis (AD) in 'at risk' Swiss children when compared to standard cow's milk formula (SF).

METHODS

Based on a 12-month time horizon including 6 months of formula consumption, an economic model was developed synthesizing treatment pathways, resource utilization, and costs associated with the treatment of AD in healthy 'at risk' Swiss newborns who could not be exclusively breastfed. Model inputs were retrieved from the literature, official formularies, and expert opinion. The treatment pathways considered a medical treatment approach, supplemented in some instances by a change of formula. The final outcome was the expected cost per avoided case of AD, yielding an incremental cost effectiveness ratio (ICER) for PHF-W vs SF. Outcomes were presented from three perspectives: the Swiss public healthcare system (MOH), the subject's family, and society (SOC). A secondary analysis compared PHF-W to whey-based extensively hydrolyzed formula (EHF) in prevention.

RESULTS

The model yielded 1653 avoided AD cases by selecting PHF-W over SF in a birth cohort of 22,933 'at risk' infants. The base case analyses generated an expected ICER of CHF 982 from the MOH perspective as well as savings of CHF 2202 and CHF 1220 from the family and SOC perspectives, respectively. PHF-W yielded CHF 11.4M savings against EHF when the latter was assumed to be used in prevention. One-way and probabilistic sensitivity analyses confirmed the robustness of the model.

CONCLUSION

Under a range of assumptions, this analysis has established the dominance from the family and societal perspectives and cost-effectiveness from the MOH perspective of PHF-W vs SF in the prevention of AD among 'at risk' Swiss infants.

Cost-effectiveness of partially-hydrolyzed formula for prevention of atopic dermatitis in Australia

OBJECTIVE

To perform an economic evaluation of a specific brand of partially hydrolyzed infant formula (PHF-W) in the prevention of atopic dermatitis (AD) among Australian infants.

METHODS

A cost-effectiveness analysis was undertaken from the perspectives of the Department of Health and Aging (DHA), of the family of the affected subject and of society as a whole in Australia, based on a decision-analytic model following a hypothetical representative cohort of Australian newborns who are not exclusively breastfed and who have a familial history of allergic disease (i.e., are deemed 'at risk'). Costs, consequences, and incremental cost-effectiveness ratios (ICER) were calculated for PHF-W vs standard cow's milk based infant formula (SF), and, in a secondary analysis, vs extensively hydrolyzed infant formula (EHF-Whey), when the latter was used for the prevention of AD.

RESULTS

From a representative starting cohort of 87,724 'at risk' newborns in Australia in 2009, the expected ICERs for PHF-W vs SF were AU$496 from the perspective of the DHA and savings of AUD1739 and AU$1243 from the family and societal perspectives, respectively. When compared to EHF-Whey, PHF-W was associated with savings for the cohort of AU$5,183,474 and AU$6,736,513 from the DHA and societal perspectives.

LIMITATIONS

The generalizability and transferability of results to other settings, populations, or brands of infant formula should be made with caution. Whenever possible, a conservative approach directing bias against PHF-W rather than its comparators was applied in the base case analysis. Assumptions were verified in one-way and probabilistic sensitivity analyses, which confirmed the robustness of the model.

CONCLUSIONS

PHF-W appears to be cost-effective when compared to SF from the DHA perspective, dominant over SF from the other perspectives, and dominant over EHF-Whey from all perspectives, in the prevention of AD in 'at risk' infants not exclusively breastfed, in Australia.

Economic evaluation of a 100% whey-based partially hydrolyzed infant formula in the prevention of atopic dermatitis among Danish children

OBJECTIVE

A pharmacoeconomic analysis was undertaken to determine costs, consequences, and cost-effectiveness of a brand of partially hydrolyzed 100%-whey formula manufactured by Nestlé (PHF-W), in the prevention of atopic dermatitis (AD) in 'at risk' Danish children compared to extensively hydrolyzed formula (EHF-Whey or Casein).

METHODS

Given the non-significant differences between PHF-W and EHF, the base case analytic approach amounted to a cost-minimization analysis (CMA) reporting the difference in formula acquisition costs over the period of formula consumption for the population of interest. However, sensitivity analyses (SAs) were undertaken to explore applying the nominal efficacy of PHF-W and EHF, thus leading to a cost-effectiveness analysis (CEA). Hence, an economic model based on a 12-month time horizon was developed synthesizing treatment pathways, resource utilization, and costs associated with the treatment of AD in the population of interest. The final economic outcome of the SAs was the incremental cost per avoided case (ICER) defined as the expected cost per avoided case of AD for PHF-W vs EHF, determined from three perspectives: the Ministry of Health (MOH), the family of the subject, and society (SOC).

RESULTS

In the base case CMA, savings of DKK 9 M, DKK 20 M, and DKK 29 M were generated for PHF-W vs EHF from the MOH, family, and SOC perspectives. In the sensitivity CEA, PHF-W was dominant over EHF-Whey from all perspectives, while EHF-Casein displayed against PHF-W unattractive ICERs of DKK 315,930, DKK 408,407, and DKK 724,337 from the MOH, family, and SOC perspectives. Probabilistic SAs indicated that PHF-W was 86% likely to be dominant over EHF-Whey, whereas EHF-Casein had no likelihood of dominating PHF-W.

CONCLUSION

Under a range of assumptions, this analysis demonstrated the attractiveness of PHF-W vs both types of EHF in the prevention of AD among 'at risk' Danish infants who are not or cannot be exclusively breastfed.

Economic evaluation of a 100% whey-based, partially hydrolysed formula in the prevention of atopic dermatitis among French children

OBJECTIVE

A pharmacoeconomic analysis was performed to determine costs, consequences and cost effectiveness of a partially hydrolysed 100% whey-based infant formula, NAN HA, manufactured by Nestlé S.A, Switzerland (PHF-W) and branded under Nidal Excel HA in France, in the prevention of atopic dermatitis (AD) in 'at risk' children when compared to standard cows' milk formula (SF) in France.

METHODS

A decision-analytic economic model depicting AD treatment pathways, as well as resource utilisation and costs associated with the treatment of AD in healthy yet 'at risk' French newborns who cannot be exclusively breastfed was constructed for a 12-month time horizon, including an initial 6 months of intervention with formula consumption. Model inputs were based on the literature, official formularies and expert opinion. The modelled treatment pathways included a dietary management approach (formula change), a medical treatment approach and a combination thereof. The final outcome was the expected cost per avoided case of AD, yielding an incremental cost per avoided case (ICER) of AD when comparing subjects who used PHF-W versus SF. Outcomes were presented from three perspectives: the French Ministry of Health (MOH), the subjects' family and society as a whole. A secondary analysis also compared PHF-W to extensively hydrolysed formula (EHF) in prevention.

RESULTS

The number of avoided AD cases by selecting PHF-W over SF was 13,356 cases in a birth cohort of 185,298 'at risk' infants. The base case analysis, at 65% reimbursement, yielded expected ICERs of €1343, € -624 (savings) and €719 from the MOH, family and societal perspectives, respectively. From all three perspectives, the highest cost was attributable to formula. In case of a 35% reimbursement rate for PHF-W, the ICER was €615 from the MOH perspective, while the use of PHF-W was cost neutral at 10% reimbursement. PHF-W was cost-saving against EHF (€98-€116 million savings depending on type of EHF), when this latter was used in prevention. One-way and probabilistic sensitivity analyses confirmed the robustness of the model.

CONCLUSION

Under a certain range of assumptions, this analysis based on predictive modelling has established the cost effectiveness of PHF-W in the prevention of AD in infants.

Regulatory environment and claims - limits and opportunities

During the past decade, the use of claims became more and more important in many countries in relation to the increased awareness of consumer about the link between foods and health, offering to industry a valuable opportunity to differentiate and valorize their products and to promote innovation. However, more and more stringent regulations are developed, all based on the general principles adopted by the Codex Alimentarius Commission. In addition to the different regulatory processes and administrative requirements according to the country, the high level (and cost) of scientific substantiation of claims, the constraints introduced by nutrient profiles and the poor knowledge of the impact on consumer depending on the cultural contexts may limit these opportunities or, at least complicate their use. All these issues are briefly analyzed, highlighting some striking convergences and differences between countries.

Parental response to health risk information: experimental results on willingness-to-pay for safer infant milk formula

Enterobacter sakazakii, a pathogen that can be found in powdered infant milk formula, can cause adverse health effects on infants. Using Vickrey auction, this study examines parents' willingness to pay (WTP) for a quality assurance label on powdered infant milk formula. The influence of ambiguity with the incidence rate information and provision of safe-handling information on WTP are also evaluated using three experimental treatments. Our findings generally imply that parents significantly value a quality assurance label. The mean price premium parents are willing to pay for the safer and quality assurance labelled powdered infant milk formula ranges from 61 to 133 Eurocents per 100 grams (53-116% of the base price per 100 grams) depending on the treatment. While no ambiguity effects are generally found, provision of safe-handling information significantly reduced WTP to 39-69 Eurocents per 100 grams depending on the treatment.

Special Supplemental Nutrition Program for Women, Infants and Children (WIC): miscellaneous vendor-related provisions. Final rule

This final rule amends the regulations governing the WIC Program to clarify issues that have arisen subsequent to the publication of the WIC Food Delivery Systems Final Rule on December 29, 2000, and to strengthen further the requirements for State vendor management and infant formula cost-containment systems. This rule contains provisions that would prohibit a State agency from requiring an infant formula manufacturer to provide free infant formula or other items in its infant formula rebate bid solicitation and contract; require that a State agency provide an abbreviated administrative review when a vendor receives a WIC civil money penalty (CMP) as a result of a Food Stamp Program (FSP) disqualification; and expand the types of vendor information that a State agency may release for general program purposes. Technical changes were also made to 7 CFR 246.16a due to revisions made to the WIC Food Packages, published in the Federal Register December 6, 2007. This rule updates regulatory citations contained in 7 CFR 246.16a that refer to 7 CFR 246.10.

Marketing infant formula through hospitals: the impact of commercial hospital discharge packs on breastfeeding

OBJECTIVES

Commercial hospital discharge packs are commonly given to new mothers at the time of newborn hospital discharge. We evaluated the relationship between exclusive breastfeeding and the receipt of commercial hospital discharge packs in a population-based sample of Oregon women who initiated breastfeeding before newborn hospital discharge.

METHODS

We analyzed data from the 2000 and 2001 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based survey of postpartum women (n=3895; unweighted response rate=71.6%).

RESULTS

Among women who had initiated breastfeeding, 66.8% reported having received commercial hospital discharge packs. We found that women who received these packs were more likely to exclusively breastfeed for fewer than 10 weeks than were women who had not received the packs (multivariate adjusted odds ratio=1.39; 95% confidence interval=1.05, 1.84).

CONCLUSIONS

Commercial hospital discharge packs are one of several factors that influence breastfeeding duration and exclusivity. The distribution of these packs to new mothers at hospitals is part of a longstanding marketing campaign by infant formula manufacturers and implies hospital and staff endorsement of infant formula. Commercial hospital discharge pack distribution should be reconsidered in light of its negative impact on exclusive breastfeeding.

The cost of infant feeding in Liverpool, England

Objective:

To investigate feeding practices in infants under the age of 4 months in Liverpool, England with particular reference to the cost of infant feeding.

Design:

A cross–sectional survey consisting of self–completion questionnaires and interviews.

Setting:

Subjects' homes within Central and South Liverpool Primary Care Trust areas.

Subjects:

One hundred and forty–nine women (aged 18 to 43 years) and their infants (mean age 13 weeks).

Results:

The average weekly cost of breast–feeding was £11.58 compared with £9.60 for formula–feeding. Many breast– and formula–feeding women spent money however on items that were not needed or used only once or twice. This was especially true of first–time mothers. Characteristics significantly associated with higher spending were: feeding method – mothers that had or were partially breast–feeding (P=0.001), education – those educated to degree level (P=0.028), socio–economic status – those in social classes I and II (P=0.002) and age – those aged 30 years and over (P=0.003).

Conclusions:

This study demonstrates that while breast–feeding is often promoted as being free, this is not the case. Better information needs to be given to parents to avoid wasting money on items that are unnecessary, or where cheaper alternatives are available.

[Our experience based on Omneo 1 /Nutrilon Comfort 1/ formula-fed of high-risk newborn babies]

OBJECTIVE

To investigate the acceptability and effect of Omneo 1/Nutrilon Comfort/milk formula of high-risk newborn babies.

METHODS

Omneo 1 was given as food to 30 high-risk newborn babies. All of them were prematurely born of an average birth gestation age-33 gestation weeks and of average weight--1757,16 gr. None of the infants was ever fed mother's milk. The intake of Omneo 1 was applied to infants of stabilized health condition and post conceptual age no less than 38 gestation weeks /the average gestation weeks were 38,96/. The following parameters were closely observed: Body weight was measured once a week with the accuracy of +/- 5 gr.; The fecal pH was measured an 20 babies by means of multicolor indication paper Merck Eurolaba GmbH, Darmstadt, Germany; Stool characteristics-consistency and frequency, regurgitation and vomiting were recorded on the basis of mother's and personals interview. Methods used--clinical analysis, inquiry method, laboratory and anthropometric measuring. The survey is prospective.

RESULTS

Weight gain was of 800 gr up to 1200 gr per month. Per day was achieved at an average weight gain - 37,60 gr. Decrease fecal pH was observed--at the beginning 7.1 (+/- 0.65) at the end of the study--5.1(+/-). The acidity of the excrements decreased which suppressed the development of pathogenic microorganisms. As regards the public inquiry, parents did not report cases an gastro-intestinal discomfort (regurgitation, constipation, colic). In two of the babies, blood in the excrements was macroscopically traced and "Allergy to cow's milk protein" was diagnosed. One of the infants was hospitalized with a generalized infection. The feeding with Omneo 1 was suspended in the case of these newborn, and they were excluded from the survey.

CONCLUSION

Parents are positive about feeding Omneo 1 despite the higher price of the product. Omneo 1 milk contributes to adequate weight growth of high-risk newborn babies and its intake results in lower fecal pH as an indicator of positive bifidus effect.

Quality of infant feeding counselling for HIV+ mothers in Brazil: challenges and achievements

AIM

This project aimed to assess the information and counselling on infant feeding in HIV+ mothers.

METHODS

A cross-sectional study, based on 118 structured observations of mothers' visits to health professionals (5-8/professional)-in 15 purposively selected HIV/Aids healthcare units in Sao Paulo.

RESULTS

The general quality of communication and counselling skills was good: for example, professionals responded to all mothers' questions (98%); kept eye-to-eye contact (82%); encouraged the mother to talk (77.1%). However, the information provided to mothers aimed to help their choices concerning infant feeding was of very poor quality. No mother, for example, was informed about alternatives to formula feeding and the danger of mixed feeding. None was offered the option of using banked breast milk. Only around 20% of mothers were informed about the safe preparation of formula feeding. When counselled by a nutritionist (compared with a paediatrician) more mothers were informed about the correct way to prepare bottle-feeds. No mention was made of cup feeding.

CONCLUSION

Although health workers have good communication skills, the information provided to HIV+ mothers is insufficient. Recommending against breast-feeding and providing infant formula may not be enough to achieve safer infant-feeding practices.

Has the WIC incentive to formula-feed led to an increase in overweight children?

We explored the relationship between the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and overweight status in children, with a focus on WIC's provision of infant formula, through secondary analyses and review of existing literature. Because of the complexity involved and the lack of previous research on the combined link between WIC, breast-feeding, and overweight status, we considered evidence for each of these relations separately. Using food-cost data from the WIC's 1996 Participant and Program Characteristics Survey, we found that the state-level average for 1 y of program benefits for women who formula-fed was over twice the value of program benefits for those who breast-fed (BF). This difference in benefit levels, or formula incentive, was negatively associated with both the in-hospital and 6-mo BF rates in state-level multiple regression models. Despite WIC's efforts to promote BF, other large-scale studies have found a negative association of program participation with BF rates. An inverse association of BF on subsequent overweight in children also has been shown in a number of studies. Despite this accumulating evidence for the protective effect of BF, it has not been seen in African American or Latino populations. In sum, there is reason to be concerned that WIC's incentive to formula-feed may have led to an increase in overweight children; yet there is too much uncertainty about the issue to conclude that this is so. Further research is needed to understand this relationship, as is the development of applied interventions to increase BF rates.

Prevalence and outcome of allergic colitis in healthy infants with rectal bleeding: a prospective cohort study

OBJECTIVES

Allergic colitis is often diagnosed clinically in healthy infants with rectal bleeding and often treated with costly hypoallergenic formula. The true prevalence of allergic colitis is unknown. We tested the hypothesis that allergic colitis is overdiagnosed in healthy infants with rectal bleeding. The authors also determined whether rectal bleeding in infants without allergic colitis would resolve without diet change.

METHODS

For the purposes of this study, allergic colitis was defined histologically as colonic mucosa with >or= 6 eosinophils per high power field and/or eosinophils in colonic crypts or muscularis mucosae. We surveyed all 56 Ohio NASPGHAN members to determine standard practice regarding the evaluation of rectal bleeding in infants. In addition, infants <or= 6 months old with rectal bleeding were recruited from the referral area of Cincinnati Children's Hospital Medical Center. All infants underwent flexible sigmoidoscopy with biopsies at 5, 10 and 15 cm. Formula or maternal diet was changed only for infants with histologic findings of allergic colitis as defined. Study subjects were followed for 9 weeks.

RESULTS

In the survey of NASPGHAN members, 84% indicated they would empirically change the diet of an infant with rectal bleeding to treat presumed allergic colitis. In our study population, however, only 14 of 22 (64%; 95% confidence interval, 41-83) infants with rectal bleeding had allergic colitis. Five (23%) had normal biopsies and three (14%) had nonspecific colitis. Rectal bleeding in all infants with normal biopsies or nonspecific colitis resolved without diet change except for 1 infant subsequently diagnosed with infantile inflammatory bowel disease.

CONCLUSION

A significant proportion of infants with rectal bleeding may not have allergic colitis and may undergo unnecessary, expensive formula or maternal diet changes that may discourage breast-feeding.

Are infant feeding options that are recommended for mothers with HIV acceptable, feasible, affordable, sustainable and safe? Pregnant women's perspectives

OBJECTIVE

To investigate pregnant women's views on infant feeding options recommended for HIV-infected women.

DESIGN

A structured interview survey complemented with focus group discussions.

SETTING

Antenatal clinics in Moshi urban and rural districts of Tanzania.

SUBJECTS

Five hundred pregnant women participated in the interview survey and 46 pregnant women participated in six focus group discussions.

RESULTS

Participating women reported that they would change to an alternative infant feeding method if they were found to be HIV-infected and were advised to do so. Cow's milk was regarded as the most feasible infant feeding method for local HIV-infected mothers. Infant feeding formula was regarded as too costly, but if recommended by health workers and distributed free of charge, the majority of the women (82%) were confident that they would then choose this option. In the focus group discussions, women were less optimistic and expressed great concern for the social consequences of not breast-feeding. The safety of exclusive breast-feeding was questioned. Less common infant feeding methods, such as expressed heat-treated breast milk and wet-nursing, were not regarded as viable options. Several social barriers to replacement feeding were identified in the focus group discussions, including possible lack of support from partner and potential negative reactions from the community.

CONCLUSION

Future research on infant feeding options should include the broader cultural context and the psychological stress that HIV-infected women face when choosing infant feeding methods.

The Delivery of Probiotics and Prebiotics to Infants

A number of studies involving the feeding of probiotics and prebiotics to infants have been published over the last decade. These studies have examined a wide range of health outcomes, including growth and safety, prophylaxis and alleviation of diarrheal disease, reduction in atopic disease, reduction in necrotizing enterocolitis, and reduction in infection of the preterm infant. In addition, these studies have described microbiological alterations observed in response to probiotic and prebiotic feeding. Collectively, the reports demonstrate that probiotics show considerable promise in addressing several health outcomes of significance to both formula-fed and breastfed infants. As quantitative and qualitative differences appear to exist between the microfloras of human-milk fed and formula-fed infants, recent innovations to infant formula have involved the inclusion of probiotics and prebiotics as a means of making the flora of the formula fed infant more similar to that of the breastfed infant. To date, only a few probiotic- and prebiotic-containing infant formulas have been marketed, but as new safety and efficacy data emerge and the regulatory climate becomes more favourable, the number of products is expected to grow.