Assessment of the risk of contamination of enteral nutrition bottles based on the simulation of home use conditions and hygiene procedures

BACKGROUND

Home-prepared enteral formulations are supplied to patients through enteral nutrition bottles, via a gravity bag or other container, which may be inadequately sanitized and reused more times than recommended by the manufacturer. Such procedures increase the risk of contamination and can compromise the patient's clinical outcome. In light of this, the present study aimed to assess the risk of contamination of enteral nutrition bottles by simulating home use conditions and hygiene procedures.

METHODS

A simulation of bottle usage was conducted across the three categories of enteral nutrition (homemade enteral preparations, blended enteral preparations, and commercial enteral formulas) for 3 days, using three hygiene procedures reported by caregivers: use of detergent (DET); use of detergent and boiling water (DET+BW); and use of detergent and bleach (DET+BL). The microbiological contamination was determined by the analysis of aerobic mesophilic microorganisms.

RESULTS

The bottles that were used for 3 days, regardless of the enteral nutrition category, were within the acceptable limit for aerobic mesophilic microorganisms (between <4 and 8.0 colony-forming units [CFU]/cm2) when sanitized using the DET+BW and DET+BL procedures. The enteral nutrition bottles, when cleaned using the DET procedure during the 3 days of usage, showed low microbial contamination (between <4 and 3.0 CFU/cm2) in blended preparation and commercial formula only.

CONCLUSION

Thus, regardless of the enteral nutrition category, we found that the bottles can be used for 3 days, as long as the DET+BW or DET+BL hygiene procedure is applied and safe food handling measures are adopted.

Determination of Bovine Lactoferrin in Powdered Infant Formula and Adult Nutritionals by Heparin Affinity Extraction and Reverse-Phase High-Performance Liquid Chromatography/Ultraviolet Detection (HPLC/UV): Single-Laboratory Validation, First Action 2021.10

BACKGROUND

Infant formulas, and pediatric and adult nutritional products, are being fortified with bovine lactoferrin (bLF) due to its beneficial impacts on immune development and gut health. Lactoferrin supplementation into these products requires an analytical method to accurately quantify the concentrations of bLF to meet global regulatory and quality standards.

OBJECTIVE

To develop and validate a lactoferrin method capable of meeting the AOAC INTERNATIONAL Standard Method Performance Requirements (SMPR®) 2020.005.

METHODS

Powder formula samples are extracted using warm dibasic phosphate buffer, pH 8, then centrifuged at 4°C to remove insoluble proteins, fat, and other solids. The soluble fraction is further purified on a HiTrap heparin solid-phase extraction (SPE) column to isolate bLF from interferences. Samples are filtered, then analyzed by LC-UV using a protein BEH C4 analytical column and quantitated using an external calibrant.

RESULTS

The LOQ (2 mg/100 g), repeatability (RSD: 2.0-4.8%), recovery (92.1-97.7%), and analytical range (4-193 mg/100 g) all meet the method requirements as stated in SMPR 2020.005 for lactoferrin.

CONCLUSION

The reported single-laboratory validation (SLV) results demonstrate the ability of this lactoferrin method to meet or exceed the method performance requirements to measure soluble, intact, non-denatured bLF in infant and adult nutritional powder formulas.

HIGHLIGHTS

The use of a heparin affinity column to isolate lactoferrin from bovine milk products combined with a selective analytical chromatographic column provides suitable analyte specificity without requiring proprietary equipment or reagents.

Nutritional profile and risk assessment of inorganic elements in enteral and parenteral nutrition formulas

The contents of essential (Ca, Fe, K, Na, P, and Zn) and potentially toxic inorganic elements (As, Al, Cd, Cr, Cu, Mn, and Pb) in enteral and parenteral nutrition formulas were evaluated by inductively coupled plasma optical emission spectrometry (ICP OES) and graphite furnace atomic absorption spectrometry (GFAAS). A total of 30 enteral formulas, 23 parenteral solution components, and 3 parenteral solutions were analyzed. The elements Ca and K presented the higher contents (72-2918 mg L-1 and 235-2760 mg L-1) while the lowest concentration levels were found for As and Cd (<0.68 µg L-1 and <0.01-0.62 µg L-1) in the studied samples. The validated analytical methods presented an accuracy of 75-116% and RSD values lower than 9.8%. Calcium gluconate and magnesium sulfate, which are used as raw materials in parenteral solution, are potential sources of Al and Mn contamination. A Hazard Quotient (HQ) >1 was obtained for Al (27 ± 1 µg L-1) in one of the parenteral samples, whereas the established limit is 25 µg L-1. Enteral samples were considered safe for consumption regarding the Al, As, and Cd levels. One healing-specific and pediatric formula contained Pb at levels above 0.25 µg kg-day-1, too high for safe consumption. The enteral formulas (pediatric, diabetes-specific, renal-specific, healing-specific, and standard formula with addition of fiber) presented risks in relation to the consumption of Cr and Mn (>250 µg day-1 and >11 mg day-1). The results indicate the need for strict monitoring, considering that these formulations are often the single patient's food source.

Analysis of Taurine in Infant Formulas and Adult Nutritionals by Hydrophilic Interaction Liquid Chromatography-Mass Spectrometry: First Action 2022.03

BACKGROUND

Taurine is recognized as an essential growth factor and as being critical in the maintenance of functional tissue regulation.

OBJECTIVE

To evaluate the analytical performance of a hydrophilic interaction liquid chromatography-tandem mass spectrometry (HILIC-MS/MS) method for compliance with AOAC Standard Method Performance Requirements (SMPR®) for taurine analysis described in SMPR 2014.013.

METHOD

Following protein precipitation with Carrez solutions, taurine is extracted and separated by HILIC with detection by triple quadrupole MS using multiple reaction monitoring (MRM). Stable isotope labeled (SIL) taurine internal standard is used for quantification to correct for losses in extraction and variations in ionization in the ion source.

RESULTS

The method was shown to meet the requirements specified in the SMPR with a linear range of 0.27-2700 mg/hg RTF (ready-to-feed), a limit of detection of 0.14 mg/hg RTF, acceptable recovery of 97.2-100.1%, and acceptable repeatability of 1.6-6.4% relative standard deviation. Additionally, the method was found to have no statistically significant bias compared with reference values for National Institute of Standards and Technology (NIST) 1849a certified reference material (CRM) (P-value = 0.95) and 1869 CRM (P-value = 0.31), and with results from AOAC 997.05 (P-value = 0.10).

CONCLUSIONS

A recent review of the method and validation data by the Stakeholder Program on Infant Formula and Adult Nutritionals (SPIFAN) Expert Review Panel (ERP) found that this method met all the criteria for analysis of taurine specified in SMPR 2014.013 and voted to adopt this method as First Action AOAC Official MethodSM2022.03.

HIGHLIGHTS

A method for the analysis of taurine in infant formulas and adult nutritionals by HILIC-MS/MS is described. A single-laboratory validation (SLV) study demonstrated the applicability of the method to meet requirements of SMPR 2014.013. In December 2022, the SPIFAN ERP voted to adopt this method as First Action AOAC Official Method 2022.03.

MICROBIOLOGICAL QUALITY OF ENTERAL FORMULATIONS HANDLED AT HOME: A SYSTEMATIC REVIEW

BACKGROUND

Studies have shown an increase in the number of patients who use enteral nutrition at home, and the benefits of this type of nutritional care. However, little is known about the risk of bacterial contamination of enteral formulations prepared at home. Therefore, the aim of the study was to assess the microbiological quality of home-prepared enteral formulations.

METHODS

This study is a systematic review, registered in PROSPERO. The search for articles was carried out in databases and gray literature. Eligible studies which microbiologically analyzed homemade enteral preparations (HEP), blended enteral preparations (BEP), and commercial enteral formulas (CEF) that were prepared at home were selected. The types and quantities of microorganisms, sources of contamination in the handling area, and the consequences of contamination (signs and symptoms) were the subjects extracted from the studies.

RESULTS

Five studies evaluated 217 enteral formulations. It was found that 72.81% of the enteral formulations exceeded the acceptable bacterial count in the case of at least one of the analyzed microorganisms. This result corresponded to 93.58% (n=73) of the HEP; 81.96% (n=50) of the BEP; and 44.87% (n=35) of the CEF. The presence of ten different microorganisms was identified in the enteral formulations, and total coliforms and mesophilic aerobics were the microorganisms found in the greatest quantity in the samples.

CONCLUSION

The three types of home-prepared enteral formulations showed unsatisfactory microbiological quality, indicating poor hygiene conditions during food handling. This article is protected by copyright. All rights reserved.

Effect of Artificial Diet on Immature Stage of the Great Eggfly, Hypolimnas bolina (Lepidoptera: Nymphalidae)

&lt;b&gt;Background and Objective:&lt;/b&gt; One of the Nymphalidae butterfly species found in West Sumatra in &lt;i&gt;Hypolimnas bolina&lt;/i&gt;. Currently, research on the artificial diet for the Nymphalidae butterfly is relatively rare in Padang, West Sumatra. The objectives of this study were to analyze the preferences of &lt;i&gt;H. bolina&lt;/i&gt; larvae, duration of the immature stage and mortality of &lt;i&gt;H. bolina&lt;/i&gt; in artificial diet treatment. &lt;b&gt;Materials and Methods:&lt;/b&gt; Some biological aspects of &lt;i&gt;H. bolina&lt;/i&gt; in corresponding to artificial diet and its effect were investigated in the laboratory. &lt;b&gt;Results:&lt;/b&gt; The result showed that there was no significant difference in the frequency of visits of the larvae in the two diet treatments namely natural (&lt;i&gt;Laportea interrupta&lt;/i&gt; leaves) and artificial diets (Sig = 0.289, p>0.05) but the duration of the visit of &lt;i&gt;H. bolina&lt;/i&gt; larvae was significantly different (Sig = 0.000, p<0.05). The visit duration of the immature stage of &lt;i&gt;H. bolina &lt;/i&gt;was significantly different, except the prepupa and pupal stage. There was no mortality of instar larvae and prepupa stage observed in both of the two-diet treatments. However, the mortality of pupae in an artificial diet was 4%. Of the total of 24 individual larvae fed with artificial diet, all of them successfully emerged, consisted of 12 males and 12 females but there was one male with abnormal wings. The average living period in the artificial diet of imago was 14.82 days for males and 16.77 days for a female. The average larval weight was no significant difference (Sig = 0.981, p>0.05) but the average pupal weight of the natural diet was slightly higher than the artificial diet. &lt;b&gt;Conclusion:&lt;/b&gt; The formulation of an artificial diet is suitable for &lt;i&gt;H. bolina&lt;/i&gt; larvae based on the results of immature mortality and adult emergences. Therefore, the formulation of an artificial diet is suitable for &lt;i&gt;H. bolina&lt;/i&gt; with its composition almost similar to &lt;i&gt;L. interrupta&lt;/i&gt; leaves (natural diet).

Single-Laboratory Validation of AOAC Official Method 2011.10 for Vitamin B12 in 'Indian' Infant and Pediatric Formulas and Adult Nutritionals

BACKGROUND

Ensuring the quality of infant and pediatric formulas and adult nutritionals is of utmost importance for the health and safety of rapidly urbanizing Indian population. B12 is an important water-soluble vitamin, which is fortified externally in such nutritional formulations. The Bureau of Indian Standards (BIS) has a recommended microbiological assay-based method for determination of vitamin B12 that is not precise and accurate enough to meet the label claim requirements of infant, adult, and/or pediatric nutritionals. The AOAC Official Method 2011.10 was originally developed under the AOAC Stakeholder Panel on Infant Formula and Adult Nutritionals (SPIFAN) for the determination of vitamin B12 in infant and pediatric formulas and adult nutritionals. However, those SPIFAN matrixes did not contain malt and other indigenous cereal and legume flour (with or without cocoa powder), which are commonly found in Indian formulations. Thus, there is a need to replace this method with a more precise and accurate method.

OBJECTIVE

This study was undertaken to validate the AOAC Official Method 2011.10 on vitamin B12 in 'Indian' infant and pediatric formulas and adult nutritionals.

METHODS

The single-laboratory validation (SLV) of AOAC Method 2011.10 was carried out as per the AOAC Guidelines in six Indian pediatric and adult nutritional formulas to verify its fitness for purpose. Cobalamin in the sample was converted to cyanocobalamin on treatment with potassium cyanide. The sample was then subjected to clean up through a C18 cartridge. Vitamin B12 in the eluted extract was separated from other components using size-exclusion column chromatography followed by a C18 column. The HPLC analysis was carried out at 550 nm.

RESULTS

Diastase treatment and C18 solid-phase extraction cleanup satisfactorily removed the matrix interference. The relative standard deviation of the determined values in 30 samples each from 6 selected Indian products and NIST SRM 1849a was <20%. The average recoveries for the spiked recovery samples ranged from 91.75 to 101.14%.

CONCLUSIONS

Method 2011.10 met the standard method performance requirements set forth by the AOAC SPIFAN. Therefore, we recommend the Method 2011.10 for adoption as the BIS official method for the analysis of vitamin B12 in 'Indian' infant and pediatric formulas and adult nutritionals.

HIGHLIGHTS

This was the first SLV project that the AOAC India section undertook to extend the scope of the AOAC Method 2011.10 for vitamin B12 analysis by validating it in 'Indian' infant and pediatric formulas and adult nutritionals.

Serum cytokine patterns are modulated in infants fed formula with probiotics or milk fat globule membranes: A randomized controlled trial

Background

Proteins and lipids of milk fat globule membrane (MFGM) and probiotics are immunomodulatory. We hypothesized that Lactobacillus paracasei ssp. paracasei strain F19 (F19) would augment vaccine antibody and T helper 1 type immune responses whereas MFGM would produce an immune response closer to that of breastfed (BF) infants.

Objective

To compare the effects of supplementing formula with F19 or bovine MFGM on serum cytokine and vaccine responses of formula-fed (FF) and BF infants.

Design

FF infants were randomized to formula with F19 (n = 195) or MFGM (n = 192), or standard formula (SF) (n = 194) from age 21±7 days until 4 months. A BF group served as reference (n = 208). We analyzed seven cytokines (n = 398) in serum at age 4 months using magnetic bead-based multiplex technology. Using ELISA, we analyzed anti-diphtheria IgG (n = 258) and anti-poliovirus IgG (n = 309) concentrations in serum before and after the second and third immunization, respectively.

Results

Compared with SF, the F19 group had greater IL-2 and lower IFN-γ concentrations (p<0.05, average effect size 0.14 and 0.39). Compared with BF, the F19 group had greater IL-2, IL-4 and IL-17A concentrations (p<0.05, average effect size 0.42, 0.34 and 0.26, respectively). The MFGM group had lower IL-2 and IL-17A concentrations compared with SF (p<0.05, average effect size 0.34 and 0.31). Cytokine concentrations were comparable among the MFGM and BF groups. Vaccine responses were comparable among the formula groups.

Conclusions

Contrary to previous studies F19 increased IL-2 and lowered IFN-γ production, suggesting that the response to probiotics differs across populations. The cytokine profile of the MFGM group approached that of BF infants, and may be associated with the previous finding that infectious outcomes for the MFGM group in this cohort were closer to those of BF infants, as opposed to the SF group. These immunomodulatory effects support future clinical evaluation of infant formula with F19 or MFGM.

The effect of cooling and rehydration methods in high moisture meat analogs with pulse proteins-peas, lentils, and faba beans

Pulse proteins (PLP) can be ideal alternative-sources that produce a meat-like textured product, known as a high moisture meat analog (HMMA). In this research, each commercial PLP: pea (16%), lentil (16%), and faba-bean (20%) was mixed with pea isolate (63%, 63%, and 59%, respectively) and constant ingredients which are canola oil (6%) and wheat gluten (15%) and texturized to produce HMMA using a twin-screw extruder (TX-52) with a cooling die. Soy concentrate and soy isolate were mixed with the constant ingredients and texturized into an HMMA and used as a control. Before freezing for storage, each sample was cooled by air, water, or a brine solution (2% or 4%) for 10 min. Frozen samples were thawed at room temperature (25 °C) for 3 hr and rehydrated by soaking at 25 °C for 2 hr, warm-soaking at 50 °C for 12 hr, or boiling for 2 min. Color, moisture content (MC), specific density (SD), water absorption index (WAI), water solubility index (WSI), and texture were measured. Compared to the control, samples with PLP had less lightness and texture and greater redness, yellowness, MC and WSI. The 2% brine solution used for cooling reduced WSI without textural change compared to other cooling methods. Boiling for rehydration increased lightness while warm-soaking decreased lightness and increased yellowness. In addition, boiling resulted in the least MC, SD, WSI, and WAI following soaking and warm-soaking. Therefore, these PLP can be used as alternative meat sources to soy proteins and a 2% brine solution for cooling and rehydration by boiling are recommended to reduce the WSI. PRACTICAL APPLICATION: Pulses are an excellent food ingredient because they are rich in protein and have an exceptional nutritional profile. In this study, high moisture meat analogs containing pea proteins, lentil proteins, faba bean proteins, and pea isolate instead of soy concentrate and soy isolate were produced. According to the results, pulse proteins can be an alternative source to soy proteins. Since they formed relatively well-defined orientation. Further research can be conducted using modified processing conditions for texturization to improve its quality. In addition, this research can help researchers and product developers understand proper handling methods for HMMA products after production such as cooling before freezing for storage and thawing and rehydrating after freezing.

Updated Food Composition Database for Cereal-Based Gluten Free Products in Spain: Is Reformulation Moving on?

We developed a comprehensive composition database of 629 cereal-based gluten free (GF) products available in Spain. Information on ingredients and nutritional composition was retrieved from food package labels. GF products were primarily composed of rice and/or corn flour, and 90% of them included added rice starch. The most common added fat was sunflower oil (present in one third of the products), followed by palm fat, olive oil, and cocoa. Only 24.5% of the products had the nutrition claim “no added sugar”. Fifty-six percent of the GF products had sucrose in their formulation. Xanthan gum was the most frequently employed fiber, appearing in 34.2% of the GF products, followed by other commonly used such as hydroxypropyl methylcellulose (23.1%), guar gum (19.7%), and vegetable gums (19.6%). Macronutrient analysis revealed that 25.4% of the products could be labeled as a source of fiber. Many of the considered GF food products showed very high contents of energy (33.5%), fats (28.5%), saturated fatty acids (30.0%), sugars (21.6%), and salt (28.3%). There is a timid reformulation in fat composition and salt reduction, but a lesser usage of alternative flours and pseudocereals.

Special Low Protein Foods in the UK: An Examination of Their Macronutrient Composition in Comparison to Regular Foods

Special low protein foods (SLPFs) are essential in a low phenylalanine diet for treating phenylketonuria (PKU). With little known about their nutritional composition, all SLPFs on UK prescription were studied (n = 146) and compared to equivalent protein-containing foods (n = 190). SLPF nutritional analysis was obtained from suppliers/manufacturers. Comparable information about regular protein-containing foods was obtained from online UK supermarkets. Similar foods were grouped together, with mean nutritional values calculated for each subgroup (n = 40) and percentage differences determined between SLPFs and regular food subgroups. All SLPF subgroups contained 43-100% less protein than regular foods. Sixty-three percent (n = 25/40) of SLPF subgroups contained less total fat with palm oil (25%, n = 36/146) and hydrogenated vegetable oil (23%, n = 33/146) key fat sources. Sixty-eight percent (n = 27/40) of SLPF subgroups contained more carbohydrate, with 72% (n = 105/146) containing added sugar. Key SLPF starch sources were maize/corn (72%; n = 105/146). Seventy-seven percent (n = 113/146) of SLPFs versus 18% (n = 34/190) of regular foods contained added fibre, predominantly hydrocolloids. Nine percent of SLPFs contained phenylalanine > 25 mg/100 g and sources of phenylalanine/protein in their ingredient lists. Stricter nutritional composition regulations for SLPFs are required, identifying maximum upper limits for macronutrients and phenylalanine, and fat and carbohydrate sources that are associated with healthy outcomes.

Design, quality, safety and efficacy of extensively hydrolyzed formula for management of cow's milk protein allergy: What are the challenges?

Cow's milk protein allergy (CMPA) is one of the most common food allergies in infancy. Clinical food allergy guidelines recommend an extensively hydrolyzed formula (EHF) as the first-line treatment in nonbreastfed infants with CMPA. Designing and commercializing EHF poses both technical and regulatory challenges. Each manufacturing step, from sourcing of raw materials to release of the final product, needs to be managed in accordance with comprehensive quality systems. To avoid cross-contamination via externally sourced ingredients, suppliers should be carefully selected based on quality requirements. Strict zoning of the manufacturing areas according to contamination risk and air flow control are effective strategies to prevent accidental allergen contamination. Furthermore, dedicated manufacturing lines for hypoallergenic products are used to prevent potential cross-contamination from other products produced on the same line. The enzymatic hydrolysis, heat treatment and ultrafiltration used are specific to each manufacturer. Consequently, EHF are a heterogenous group of products with differences in the molecular weight profile of peptides, content of residual immunogenic cow's milk allergens, and residual in-vitro allergenicity. These differences are likely to affect clinical efficacy and safety. As not all commercialized EHF products have undergone formal testing in the laboratory and clinical trials, there is a need to develop guidelines for minimum technical and regulatory requirements for EHF products, including validated assays for ongoing quality control. Clinical trials assessing new EHF products for their hypoallergenicity and ability to support normal growth remain the definitive proof of efficacy and safety in infants and young children with CMPA.

Chloride in Milk, Milk Powder, Whey Powder, Infant Formula, and Adult Nutritionals Potentiometric Titration: Collaborative Study, Final Action 2016.03

Background: In September 2015, both AOAC Official Methods 2015.07 and 2015.08 single-laboratory validations (SLVs) were reviewed against Standard Method Performance Requirements® (SMPR) 2014.015 by the AOAC Stakeholder Panel for Infant Formula and Adult Nutritional (SPIFAN) Expert Review Panel (ERP). Looking at the similarity and uniqueness of the two methods, the authors agreed, as advised by the ERP, to work together to merge the two methods into one. This combined method was assigned Method 2016.03. Objective: In order to determine the repeatability and reproducibility of the AOAC First Action 2016.03 method, a collaborative study was organized. The study was divided in two parts: (Part 1) method set up and qualification of participants and (Part 2) collaborative study participation. During Part 1, each laboratory was asked to analyze two practice samples. The laboratories that provided results within a range of expected levels were qualified for Part 2, during which they analyzed 25 samples in blind duplicates. Results: The results were compared with SMPR 2014.015 established for chloride. The precision results (repeatability and reproducibility) were within the requirements stated in the SMPR. In general, the precision results (repeatability and reproducibility) were well within the limits stated in the SMPR. Repeatability ranged from 0.4 to 1.9%, in accordance with data obtained during SLV, with reported RSD of repeatability from 0.03 to 1.6%. Meanwhile, reproducibility ranged from 0.6 to 4.0%. Finally, the Horwitz ratio values were all below 1, from 0.2 to 0.9%. Conclusions: The ERP determined that the data presented met the SMPR and accordingly recommended the method to be granted Final Action status. In January 2018, the Official Methods Board approved the method as Final Action.

Protein Oxidation in Plant Protein-Based Fibrous Products: Effects of Encapsulated Iron and Process Conditions

Plant protein-based fibrous structures have recently attracted attention because of their potential as meat replacer formulations. It is, however, unclear how the process conditions and fortification with micronutrients may affect the chemical stability of such products. Therefore, we aimed to investigate the effects of process conditions and the incorporation of iron (free and encapsulated) on protein oxidation in a soy protein-based fibrous product. First, the physicochemical stability of iron-loaded pea protein particles, used as encapsulation systems, was investigated when exposed to 100 or 140 °C. Second, protein oxidation was measured in the iron-fortified soy protein-based fibrous structures made at 100 or 140 °C. Exposure to high temperatures increased the carbonyl content in pea protein particles. The incorporation of iron (free or encapsulated) did not affect carbonyl content in the fibrous product, but the process conditions for making such products induced the formation of carbonyls to a fairly high extent.

Maximizing Recovery and Growth When Treating Moderate Acute Malnutrition with Whey-Containing Supplements

BACKGROUND

Much debate exists about the utility of dairy ingredients in the supplementary foods used to treat childhood moderate acute malnutrition (MAM).

OBJECTIVE

To review the evidence regarding the effectiveness of dairy-containing supplements, particularly specially formulated foods containing whey permeate and whey protein concentrate, in treating children with MAM.

METHODS

A summary of a conference presentation regarding an overview of current evidence behind the use of whey in supplementary foods, including results of a randomized double-blinded clinical effectiveness trial involving 2259 Malawian children treated for MAM using either a soy ready-to-use supplementary food (RUSF) or a novel whey RUSF treatment.

RESULTS

While the majority of the evidence base only suggests potential benefits of including whey in supplementary foods to treat MAM, a recent study specifically demonstrates that a whey RUSF produced superior recovery and growth outcomes in treating children with MAM when compared with a soy RUSF.

CONCLUSIONS

The use of whey ingredients has been shown to improve outcomes in the treatment of MAM; however, further research is needed to identify the ideal amount and type of dairy protein required to produce the best outcomes for the lowest cost.

Characterization and Quantification of Oligosaccharides in Human Milk and Infant Formula

Oligosaccharides are known to affect the health of infants. The analysis of these complex molecules in (human) milk samples requires state-of-the-art techniques. This study analyzed the composition and concentration of oligosaccharides in early (day 3) and mature (day 42) human milk as well as in five different infant formula brands. The oligosaccharide content decreased in human milk from 9.15 ± 0.25 g/L at day 3 to 6.38 ± 0.29 g/L at day 42 of lactation. All formulas resulted to be fortified with galacto-oligosaccharides, with one also fortified with polydextrose and another with long-chain fructo-oligosaccharides. About 130 unique oligosaccharide structures were identified in the human milk samples, whereas infant formula contained less diversity of structures. The comparisons indicated that composition and abundance of oligosaccharides unique to human milk are not yet reproduced in infant formulas. The analytical workflow developed is suitable for the determination of prebiotic oligosaccharides in foods that contain diverse carbohydrate structures.

Use of Textured Thin Liquids in Patients With Dysphagia

PURPOSE

The goals of this article are to explore the use of textured thin liquids for dysphagic patients who require thickened liquids and to illustrate their impact on hydration and patient satisfaction.

METHOD

A retrospective evaluation of textured thin liquids was completed using patient data looking at laboratory values relevant to the detection of dehydration (blood urea nitrogen, creatinine, sodium) and patient satisfaction (using a clinician-generated questionnaire) on different modified liquid textures. In addition, the viscosity for all liquids was tested using a rheometer.

RESULTS

Measurements show that the viscosity of the textured thin liquids examined in this pilot study are significantly lower than the viscosity of nectar-thick liquids and fall within the "thin" category as defined by the National Dysphagia Diet guidelines. Patients on honey- and nectar-thick liquids had laboratory values signifying dehydration, whereas those receiving the textured thin liquid consistency were within the normal range for all laboratory values. Importantly, when consuming textured thin liquids, patients reported significant improvement in their satisfaction related to their thirst.

CONCLUSION

The results of this pilot study highlight the consequences of common thickened liquid dietary recommendations and of the potentially beneficial clinical application of textured thin liquids for patients with dysphagia as well as the need for future prospective research.

Vitamin B12 (cyanocobalamin) in Infant Formula Adult/Pediatric Nutritional Formula by Liquid Chromatography with Ultraviolet Detection: Collaborative Study, Final Action 2014.02

To determine the repeatability and reproducibility figures of the AOAC First Action Official MethodSM 2014.02 (Vitamin B12 in Infant Formula and Adult/Pediatric Formula by Liquid Chromatography with UV Detection), a collaborative study was organized. Twenty-one laboratories located in 13 different countries agreed to participate. The study was divided into two parts. During the first part, the laboratories analyzed two samples in duplicate by using the method described in the protocol. The laboratories that provided results within the expected range were qualified for part two, during which they analyzed 10 samples in blind duplicates. Eighteen laboratories managed to provide results on time for reporting. The results were compared with the Standard Method Performance Requirement (SMPR® 2011.005) established for vitamin B12. The precision results met the requirements stated in the SMPR except for one sample. Repeatability and reproducibility relative standard deviation ranged from 1.1 to 6.5% and from 6.0 to 23.8%, respectively, with only one matrix showing reproducibility values higher than the required 11%. Horwitz ratio values were all well below 2 (0.17-0.78). The AOAC Expert Review Panel (Stakeholder Panel for Infant Formula and Adult Nutritional Expert Review Panel) determined that the data presented met the SMPR and, hence, recommended the method to be granted Final Action status in September 2016.

Estimating the health and economic effects of the proposed US Food and Drug Administration voluntary sodium reformulation: Microsimulation cost-effectiveness analysis

BACKGROUND

Sodium consumption is a modifiable risk factor for higher blood pressure (BP) and cardiovascular disease (CVD). The US Food and Drug Administration (FDA) has proposed voluntary sodium reduction goals targeting processed and commercially prepared foods. We aimed to quantify the potential health and economic impact of this policy.

METHODS AND FINDINGS

We used a microsimulation approach of a close-to-reality synthetic population (US IMPACT Food Policy Model) to estimate CVD deaths and cases prevented or postponed, quality-adjusted life years (QALYs), and cost-effectiveness from 2017 to 2036 of 3 scenarios: (1) optimal, 100% compliance with 10-year reformulation targets; (2) modest, 50% compliance with 10-year reformulation targets; and (3) pessimistic, 100% compliance with 2-year reformulation targets, but with no further progress. We used the National Health and Nutrition Examination Survey and high-quality meta-analyses to inform model inputs. Costs included government costs to administer and monitor the policy, industry reformulation costs, and CVD-related healthcare, productivity, and informal care costs. Between 2017 and 2036, the optimal reformulation scenario achieving the FDA sodium reduction targets could prevent approximately 450,000 CVD cases (95% uncertainty interval: 240,000 to 740,000), gain approximately 2.1 million discounted QALYs (1.7 million to 2.4 million), and produce discounted cost savings (health savings minus policy costs) of approximately $41 billion ($14 billion to $81 billion). In the modest and pessimistic scenarios, health gains would be 1.1 million and 0.7 million QALYS, with savings of $19 billion and $12 billion, respectively. All the scenarios were estimated with more than 80% probability to be cost-effective (incremental cost/QALY < $100,000) by 2021 and to become cost-saving by 2031. Limitations include evaluating only diseases mediated through BP, while decreasing sodium consumption could have beneficial effects upon other health burdens such as gastric cancer. Further, the effect estimates in the model are based on interventional and prospective observational studies. They are therefore subject to biases and confounding that may have influenced also our model estimates.

CONCLUSIONS

Implementing and achieving the FDA sodium reformulation targets could generate substantial health gains and net cost savings.

Enteral nutritional therapy for induction of remission in Crohn's disease

BACKGROUND

Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta-analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review.

OBJECTIVES

To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts.

SELECTION CRITERIA

Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random-effects model was used to pool data. We performed intention-to-treat and per-protocol analyses for the primary outcome. Heterogeneity was explored using the Chi² and I² statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes.

MAIN RESULTS

Twenty-seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non-elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non-elemental diets differing in glutamine enrichment. Meta-analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty-four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non-elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per-protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non-elemental diets (elemental, semi-elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non-elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating.Ten trials compared EN to steroid therapy. Meta-analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per-protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per-protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet.

AUTHORS' CONCLUSIONS

Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy.

Indigenous food ingredients for complementary food formulations to combat infant malnutrition in Benin: a review

This paper reviews indigenous Beninese food resources as potential ingredients for complementary infant foods with the aim to develop affordable formulations for low-income households in each agro-ecological zone of the country. Potential ingredients were selected on their documented nutritional value. The selected foods encompass 347 food resources, namely 297 plant products from home gardens or collected from natural vegetation and 50 animals, either domesticated or from the wild. The compiled data reveal that the distribution of the available food resources was unbalanced between agro-ecological zones. Only a few animal ingredients are obtainable in northern Benin. Most resources are seasonal, but their availability may be extended. A high variation was observed in energy and nutrient contents. Antinutritional factors were identified in some resources, but processing techniques were reported to reduce their presence in meals. In general, ingredients from local tree foods (Adansonia digitata, Parkia biglobosa) were adequate as sources of nutrients for complementary infant foods. Based on this review, local foods for the development of complementary food formulas for Beninese infants and children may be selected for each agro-ecological zone. The approach used is exemplary for other sub-Saharan African countries in need of complementary infant foods. © 2017 Society of Chemical Industry.

Formulation and Evaluation of Functional Cookies for Improving Health of Primary School Children

BACKGROUND AND OBJECTIVE

School children especially in Egypt need a safe meal which is able to meet their daily nutrient needs and ameliorate cognition. So, the current study aimed to evaluate formula prepared as cookies to be served as a meal for primary school children.

MATERIALS AND METHODS

Wheat, roasted chickpea, milk protein concentrate, cinnamon and brewer's yeast were used to prepare cookies which have been exposed to sensory, chemical and biological evaluation. Peroxide number, amino acids, vitamins (D, B12, folic acid and E) and minerals (calcium, zinc, iron and selenium) were determined. Twenty four rats of weaning age were used, 12 rats to estimate the true protein digestibility and 12 rats to estimate the protein efficiency ratio and the effect of feeding on cookies (28 days) on hemoglobin, glucose, total protein, liver and kidney functions and antioxidant status.

RESULTS

Palatability and acceptability of cookies were insured via the sensory evaluation results. The value of peroxide number indicated that there is no possibility of rancidity during the storage. The cookies showed high contents of protein (14.88%), fat (16.83%) and carbohydrate (55.1%). Also cookies showed acceptable levels of amino acids, minerals and vitamins that meet a large amount of daily requirements of children. Results of the animal experiment declared the complete safety of the cookies and high nutritional and biological quality.

CONCLUSION

Cookies can serve as a meal for the governmental school children to provide them with their needs from nutrients that reducing hunger and improving health benefits and scholastic achievement.

Diet improvement for western corn rootworm (Coleoptera: Chrysomelidae) larvae

The western corn rootworm (WCR), Diabrotica virgifera virgifera LeConte, is the most serious insect pest of corn (Zea mays L.) in the United States and parts of Europe, and arguably one of the world’s most expensive pests to control. Several diet formulations are currently used by industry and public researchers to evaluate WCR larvae in diet-toxicity bioassays. However, a publicly available diet that produces normative insects that are physiologically similar to WCR larvae reared on corn roots will accelerate development of management technologies. We report a new diet formulation that supports improved weight gain, larval development and survival compared with the only public diet for WCR that is currently available in the refereed literature. The formulation was created by using response surface methods combined with n-dimensional mixture designs to identify and improve the formulation of key ingredients. Weight gain increased two-fold, and survival and molting rates increased from 93% and 90%, respectively when reared on the public diet, to approximately 99% for both survival and molting at 11 days when reared on our new formulation. This new formulation provides a standardized growth medium for WCR larvae that will facilitate comparison of research results from various working groups and compliance with regulatory requirements.

Analysis of Vitamin D₂ and Vitamin D₃ in Infant and Adult Nutritional Formulas by Liquid Chromatography-Tandem Mass Spectrometry: A Multilaboratory Testing Study

A multilaboratory testing study was conducted on AOAC First Action Method 2016.05 "Analysis of Vitamin D2 and Vitamin D3 in Fortified Milk Powders, Infant Formulas, and Adult/Pediatric Nutritional Formulas by Liquid Chromatography-Tandem Mass Spectrometry." Nine laboratories participated in the analysis of duplicate samples of 20 nutritional products. The samples were saponified at high temperature with lipid-soluble components extracted into isooctane; an aliquot was washed and vitamin D derivatized with 4-phenyl-1,2,4-triazoline-3,5-dione to form a high-molecular mass, easily ionizable adduct, extracted into acetonitrile and analyzed by reversed-phase LC-tandem MS. Stable isotope-labeled internal standards were used for quantitation to correct for losses in extraction and variation in derivatization and ionization efficiencies. Acceptable precision as RSD was demonstrated; repeatability ranged from 1.9 to 5.8% RSDr and reproducibility values ranged from 6.4 to 12.7% RSDR, with samples meeting the precision limits specified in the vitamin D Standard Method Performance Requirements and the guidelines recommended for the Horwitz ratio. Method accuracy was assessed using NIST 1849a Standard Reference Material, with a P-value of 0.32, indicating an absence of bias against the certified value. As expected, placebo samples not fortified with vitamin D returned negligible results.

Determination of Lutein and β-Carotene in Infant Formula and Adult Nutritionals by Ultra-High-Performance Liquid Chromatography: Single-Laboratory Validation, First Action 2016.13

An ultra-HPLC method for the determination of lutein and β-carotene in infant formula and adult nutritionals was validated using both unfortified and fortified samples provided by the AOAC Stakeholder Panel on Infant Formula and Adult Nutritionals (SPIFAN). All experiments showed separation of all-trans-lutein and β-carotene from their major cis isomers, apocarotenal, α-carotene, lycopene, and zeaxanthin. Samples spiked with all-trans-lutein and β-carotene showed no isomerization during sample preparation. Linearity of the calibration solutions correlated to approximately 0.8-45 μg/100 g (reconstituted basis) for samples prepared for the lowest sample concentrations. With dilutions specified in the method, the range can be extended to approximately 2250 μg/100 g. The LOD for both lutein and β-carotene was 0.08 μg/100 g, and the LOQ for both was 0.27 μg/100 g. For all measurements in the range of 1-100 μg/100 g, repeatability RSD was ≤5.8% for lutein and ≤5.1% for β-carotene. For measurements >100 μg/100 g, repeatability RSD was ≤1.1% for lutein and ≤1.7% for β-carotene. Accuracy was determined by recovery from spiked samples and ranged from 92.3 to 105.5% for lutein and from 100.1 to 107.5% for β-carotene. The data provided show that the method meets the criteria specified in the Standard Method Performance Requirements for carotenoids (SMPR 2014.014).