Infants exposure to aflatoxin M1 as a novel foodborne zoonosis

Prevalence and concentration of aflatoxin M1 in breast milk in Africa: a meta-analysis and implication for the interface of agriculture and health

Breast milk is one of the many distinct forms of food that can be contaminated with aflatoxin M1 (AFM1). They may be consumed by eating contaminated foods, such as contaminated meat and crops, which would then be present in breast milk and cause health problems, including nervous system disorders and cancers of the lungs, liver, kidneys, and urinary tract. However, the prevalently inconsistent explanation of prevalence and concentration remains a big challenge. Thus, this meta-analysis was conducted to determine the prevalence and concentration of harmful chemicals in breast milk in an African context. The databases MEDLINE, PubMed, Embase, SCOPUS, Web of Science, and Google Scholar were searched for both published and unpublished research. To conduct the analysis, the collected data were exported to Stata version 18. The results were shown using a forest plot and a prevalence with a 95% confidence interval (CI) using the random-effects model. The Cochrane chi-square (I2) statistics were used to measure the studies' heterogeneity, and Egger's intercept was used to measure publication bias. This review included twenty-eight studies with 4016 breast milk samples and newborns. The analysis showed the overall prevalence and concentration of aflatoxin M1 in breast milk were 53% (95% CI 40, 65; i2 = 98.26%; P = 0.001). The pooled mean aflatoxin M1 concentration in breast milk was 93.02 ng/l. According to this study, the eastern region of Africa was 62% (95% CI 39-82) profoundly affected as compared to other regions of the continent. In subgroup analysis by publication year, the highest level of exposure to aflatoxins (68%; 95% CI 47-85) was observed among studies published from 2010 to 2019. This finding confirmed that more than half of lactating women's breast milk was contaminated with aflatoxin M1 in Africa. The pooled mean aflatoxin M1 concentration in breast milk was 93.02 ng/l. According to this study, the eastern region of Africa was profoundly affected compared with other regions. Thus, the government and all stakeholders must instigate policies that mitigate the toxicity of aflatoxins in lactating women, fetuses, and newborns.

Mycotoxin contamination in the Arab world: Highlighting the main knowledge gaps and the current legislation

Since the discovery of aflatoxins in the 1960s, knowledge in the mycotoxin research field has increased dramatically. Hundreds of review articles have been published summarizing many different aspects, including mycotoxin contamination per country or region. However, mycotoxin contamination in the Arab world, which includes 22 countries in Africa and Asia, has not yet been specifically reviewed. To this end, the contamination of mycotoxins in the Arab world was reviewed not only to profile the pervasiveness of the problem in this region but also to identify the main knowledge gaps imperiling the safety of food and feed in the future. To the best of our knowledge, 306 (non-)indexed publications in English, Arabic, or French were published from 1977 to 2021, focusing on the natural occurrence of mycotoxins in matrices of 14 different categories. Characteristic factors (e.g., detected mycotoxins, concentrations, and detection methods) were extracted, processed, and visualized. The main results are summarized as follows: (i) research on mycotoxin contamination has increased over the years. However, the accumulated data on their occurrences are scarce to non-existent in some countries; (ii) the state-of-the-art technologies on mycotoxin detection are not broadly implemented neither are contemporary multi-mycotoxin detection strategies, thus showing a need for capacity-building initiatives; and (iii) mycotoxin profiles differ among food and feed categories, as well as between human biofluids. Furthermore, the present work highlights contemporary legislation in the Arab countries and provides future perspectives to mitigate mycotoxins, enhance food and feed safety, and protect the consumer public. Concluding, research initiatives to boost mycotoxin research among Arab countries are strongly recommended.

Human Breast Milk Contamination with Aflatoxins, Impact on Children's Health, and Possible Control Means: A Review

Aflatoxins are natural toxicants produced mainly by species of the Aspergillus genus, which contaminate virtually all feeds and foods. Apart from their deleterious health effects on humans and animals, they can be secreted unmodified or carried over into the milk of lactating females, thereby posing health risks to suckling babies. Aflatoxin M1 (AFM1) is the major and most toxic aflatoxin type after aflatoxin B1 (AFB1). It contaminates human breast milk upon direct ingestion from dairy products or by carry-over from the parent molecule (AFB1), which is hydroxylated in the liver and possibly in the mammary glands by cytochrome oxidase enzymes and then excreted into breast milk as AFM1 during lactation via the mammary alveolar epithelial cells. This puts suckling infants and children fed on this milk at a high risk, especially that their detoxifying activities are still weak at this age essentially due to immature liver as the main organ responsible for the detoxification of xenobiotics. The occurrence of AFM1 at toxic levels in human breast milk and associated health conditions in nursing children is well documented, with developing countries being the most affected. Different studies have demonstrated that contamination of human breast milk with AFM1 represents a real public health issue, which should be promptly and properly addressed to reduce its incidence. To this end, different actions have been suggested, including a wider and proper implementation of regulatory measures, not only for breast milk but also for foods and feeds as the upstream sources for breast milk contamination with AFM1. The promotion of awareness of lactating mothers through the organization of training sessions and mass media disclosures before and after parturition is of a paramount importance for the success of any action. This is especially relevant that there are no possible control measures to ensure compliance of lactating mothers to specific regulatory measures, which can yet be appropriate for the expansion of breast milk banks in industrialized countries and emergence of breast milk sellers. This review attempted to revisit the public health issues raised by mother milk contamination with AFM1, which remains undermined despite the numerous relevant publications highlighting the needs to tackle its incidence as a protective measure for the children physical and mental health.

Quantitative analysis and carcinogenic/non-carcinogenic risk assessment of aflatoxin M1 in milk-based baby food and infant formula milk - a case study in Iran

In this study, solid-phase extraction (SPE) combined with the dispersive liquid-liquid microextraction based on novel hydrophobic deep eutectic solvent (DLLME - DES) has been developed as an ultra-pre-concentration technique for the extraction of aflatoxin M₁ (AFM1) in milk-based baby food (MBBF) and infant formula milk (IFM) samples followed by HPLC combined with fluorescence detection (HPLC - FL). In addition, carcinogenic and non-carcinogenic risk assessment was performed by health-related risk factors including liver cancer risk (LCR), margin of exposure (MOE) and target hazard quotient (THQ) were calculated using the mean of AFM1 in different infant food samples. The results of the study showed that the mean of AFM1 was statistically significant different between various brands and types of IFM and MBBF. The results of the study showed that the percentage of positive samples higher than the allowable limit of AFM1 in 36 samples of domestic infant formula milk (DIFM), 24 samples of imported infant formula milk (IIFM), 36 samples of domestic milk-based baby food (DMBBF) and 18 samples of imported milk-based baby food (IMBBF) were 41.6, 12.5, 66.7 and 33.3%, respectively. In addition, estimated values for health risk-related factors including LCR, MOE and THQ indicated that for most infants less than one-year-old were higher than the acceptable levels. Based on the results, it can be concluded that the quality of IFM and MBBF consumed in Iran in terms of AFM1 is poor. Therefore, it is necessary to take appropriate measures to reduce the amount of AFM1 in DIFM and DMBBF, and in addition, the IIFM and IMBBF should be controlled qualitatively before supplying the market.

Aflatoxin B1 Occurrence in Children under the Age of Five's Food Products and Aflatoxin M1 Exposure Assessment and Risk Characterization of Arab Infants through Consumption of Infant Powdered Formula: A Lebanese Experience

Aflatoxin M1 (AFM1) is a salient metabolite that can be used to assess Aflatoxin B₁ (AFB1) exposure in humans and animals. The carcinogenic potency of AFB1 and AFM1 was severely reported. The aims of this study were (1) to survey the contamination level of AFM1 in the most traded infant powdered formula brands (IPF) (n = 42) along with the AFB1 level in under 5's children food brands (biscuits, cornflakes, and cereals) (n = 42) and (2) to assess the estimated daily intake (EDI), the hazard quotient (HQ) and the margin of exposure (MOE) of AFM1 among infants (0-12 months) in Lebanon. All of the samples were analyzed using ELISA technique. AFB1 was below detection limit in all of the children's food brands samples. Out of 42 IPF samples 9.5% were AFM1-positive in the range of 29.54-140.16 ng/L and exceeded the maximum tolerable limit (MTL) set by the European commission (25 ng/kg). The overall average contamination level was 5.72 ± 0.014 ng/L. The EDI of AMF1 for male was in the range of 0.37-0.78 ng/kg/b.w./day and 0.40-0.87 ng/kg/b.w./day for females. Similarly, the HQ calculation resulted in an average of 3.05 for males and 3.28 for females. MOE calculations were far lower from 10,000 in both genders which indicates a high risk of genotoxicity and carcinogenicity. Our findings show that AFM1's EDI, HQ and MOE scored high among Lebanese infants. As infants consume more IPF relative to their body weight, the persistence of IPF with high AFM1 levels threatens their health. Thus, infant's exposure risk to AFM1 in IPF should be a continuous focus of attention.

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

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

Levels of Aflatoxin M1 in Breast Milk of Lactating Mothers in Monterrey, Mexico: Exposure and Health Risk Assessment of Newborns

The present study aimed to determine the presence of the aflatoxin M1 (AFM1) in breast milk samples from 123 nursing women and the degree of exposure of infants to this toxin, in the metropolitan area of Monterrey, Nuevo Leon state (northeast Mexico). Upon analysis, 100% of the samples were found to be contaminated with the toxin at an average concentration of 17.04 ng/L, with a range of 5.00 to 66.23 ng/L. A total of 13.01% of the breast milk samples exceeded the regulatory limit of 25 ng/L for AFM1 concentration, set by the European Union. The estimated daily intake for AFM1 and the carcinogenic risk index were also determined in the 0- to 6-, 7- to 12-, 13- to 24-, and 25- to 36-month-old age groups. The AFM1 intake through breast milk ranged from 1.09 to 20.17 ng/kg weight/day, and was higher than the tolerable daily intake, indicating a carcinogenic risk for infants in the age groups of 0- to 24-months old. This evidence demonstrates a susceptibility of breast milk to AFM1 contamination that may suggest a carcinogenic risk for the breastfed infants in Monterrey city, Nuevo Leon state, and the need to control the presence of aflatoxins in foods eaten by nursing mothers.

Mycotoxin-mixture assessment in mother-infant pairs in Nigeria: From mothers' meal to infants' urine

Exposure to food and environmental contaminants is a global environmental health issue. In this study, innovative LC-MS/MS approaches were applied to investigate mycotoxin co-exposure in mother-infant pairs (n = 23) by analyzing matched plate-ready food, breast milk and urine samples of mothers and their exclusively breastfed infants. The study revealed frequent co-occurrence of two to five mycotoxins. Regulated (e.g. aflatoxins, deoxynivalenol and ochratoxin A) and emerging mycotoxins (e.g. alternariol monomethyl ether and beauvericin) were frequently detected (3 %-89 % and 45 %-100 %), in at least one specimen. In addition, a moderate association of ochratoxin A in milk to urine of mothers (r = 0.47; p = 0.003) and infants (r = 0.52; p = 0.019) but no other significant correlations were found. Average concentration levels in food mostly did not exceed European maximum residue limits, and intake estimates demonstrated exposure below tolerable daily intake values. Infants were exposed to significantly lower toxin levels compared to their mothers, indicating the protective effect of breastfeeding. However, the transfer into milk and urine and the resulting chronic low-dose exposure warrant further monitoring. In the future, occurrence of mycotoxin-mixtures, and their combined toxicological effects need to be comprehensively considered and implemented in risk management strategies. These should aim to minimize early-life exposure in critical developmental stages.

Human Biomonitoring of Selected Hazardous Compounds in Portugal: Part II—Lessons Learned on Mycotoxins

Human biomonitoring (HBM) data provide information on total exposure regardless of the route and sources of exposure. HBM studies have been applied to quantify human exposure to contaminants and environmental/occupational pollutants by means of determining the parent compounds, their metabolites, or even their reaction products in biological matrices. HBM studies performed among the Portuguese population are dispersed and limited. Thus, to overcome this knowledge gap, this work reviews the published Portuguese HBM information concerning mycotoxins detected in the urine, serum, milk, hair, and nails of different groups of the Portuguese population. This integrative approach to the available HBM data allows us to analyze the main determinants and patterns of exposure of the Portuguese population to the selected hazardous compounds, as well as to assess the potential health risks. We also aimed to identify the main difficulties and challenges of HBM through the analysis of the enrolled studies. Ultimately, this study aims to support national and European policies in promoting human health by summarizing the most important outcomes and lessons learned through the HBM studies carried out in Portugal.

Evaluation of Mycotoxins in Infant Breast Milk and Infant Food, Reviewing the Literature Data

In this review, an analysis focusing on mycotoxin determination in infant breast milk and infant food has been summarised for the last fifteen years of research focused on the intended population group of 1-9 months. The objective was to know the level of exposure of the child population to an estimated daily intake (EDI) of mycotoxins from the consumption of habitual foods. The EDI was compared with the tolerable daily intake (TDI) established by EFSA to estimate risk. In breast milk, the high prevalence and levels were for samples from Africa (Egypt and Tanzania) with aflatoxin M1 (1.9 μg/L and 10%), and Asia (Iran) with ochratoxin-A (7.3 μg/L and 100%). In infant formulas, high incidences and values were for samples with aflatoxin M1 from Burkina Faso (167 samples, 84%, 87 μg/kg). In cereal products, the highest incidence was for DON from the United States (96 samples), and the highest value was an Italian sample (0.83 μg/kg of enniatin B). In fruit products, patulin was the most detected in Italian (78) and Spanish (24) samples. The highest risk was observed in breast milk during the first month of age, the highest EDI for aflatoxin M1 was reported for Egypt (344-595 ng/kg bw/day) and ochratoxin-A for Iran (97-167ng/kg bw/day), representing a public health problem.

Occurrence of aflatoxin M1 in human breast milk in Bangladesh

Breast milk is the best, most complete form of nutrition for newborns and infants. However, human milk can contain aflatoxin M₁ (AFM₁) upon ingestion of dietary mycotoxin contaminants, namely, aflatoxin B₁ (AFB₁), by lactating mothers. AFB₁ and its hydroxylated metabolite AFM₁ are potent carcinogens and thus an important issue in food safety and public health. This study is the first to explore the presence of AFM₁ in breast milk samples from Bangladesh and assess infant exposure to this toxin, as a consequence of maternal mycotoxin intake. A total of 62 breast milk samples were collected from nursing mothers in Sylhet region of Bangladesh. The milk samples were collected between October 2019 and March 2020 and analyzed by a sensitive enzyme-linked immunosorbent assay. AFM₁ was detected in 51.6% of the breast milk samples (colostrum, transitional and mature milk), with a mean concentration of 4.42 ± 0.56 pg/mL, and in the range between LOD (4.0 pg/mL) and 6.66 pg/mL. The frequent detection of AFM₁ in breast milk indicates widespread dietary exposure to mycotoxins in our cohort. The estimated average daily intake of AFM₁ for all nursed infants was 0.49 ng/kg b.w./day. No significant correlations were observed between AFM₁ levels in human milk and food items regularly consumed by nursing women. Overall, AFM₁ levels in breast milk samples from the Sylhet region of Bangladesh are moderate, and lower than the permissible levels established for AFM₁ in dairy milk or infant formulae (50 and 25 ng/kg, respectively). Yet, this first data for AFM₁ breast milk contaminant levels just reflect the recent situation in one cohort, and monitoring should be continued.

Risk of dietary and breastmilk exposure to mycotoxins among lactating women and infants 2-4 months in northern India

Mycotoxins are carcinogenic secondary metabolites of fungi that have been linked to infant growth faltering. In this study, we quantified co-occurring mycotoxins in breast milk and food samples from Haryana, India, and characterized determinants of exposure. Deterministic risk assessment was conducted for mothers and infants. We examined levels of eight mycotoxins (Aflatoxin B1 , B2 , G1 , G2 , M1 , M2 ; Ochratoxin A, B) in 100 breast milk samples (infants 2-4 months) using ultra-high-performance liquid chromatography tandem mass spectrometry. Aflatoxin B1 (AFB1 ), fumonisin B1 (FB1 ) and deoxynivalenol (DON) were detected in several food items (n = 298) using enzyme-linked immunosorbent assays. We report novel data on the presence of mycotoxins in breast milk samples from India. Whereas breast milk concentrations (AFM1 median: 13.7; range: 3.9-1200 ng/L) remain low, AFM1 was detected above regulatory limits in 27% of animal milk samples. Additionally, 41% of infants were above provisional maximum tolerable daily intake (PMTDI) limits for AFM1 due to consumption of breast milk (mean: 3.04, range: 0.26-80.7 ng kg-1 bw day-1 ). Maternal consumption of breads (p < 0.05) was associated with breast milk AFM1 exposure. AFB1 (μg/kg) was detected in dried red chilies (15.7; 0-302.3), flour (3.13; 0-214.9), groundnuts (0; 0-249.1), maize (56.0; 0-836.7), pearl millet (1.85; 0-160.2), rice (0; 0-195.6), wheat (1.9; 0-196.0) and sorghum (0; 0-63.5). FB1 (mg/kg) was detected in maize (0; 0-61.4), pearl millet (0; 0-35.4) and sorghum (0.95; 0-33.2). DON was not detected in food samples. Mothers in our study exceeded PMTDI recommendations for AFB1 due to consumption of rice and flour (mean: 75.81; range: 35.2-318.2 ng kg-1 bw day-1 ). Our findings show the presence of Aflatoxin B1 and M1 at various levels of the food chain and in breast milk, with estimated intakes exceeding PMTDI recommendations. Aflatoxins are known carcinogens and have also been linked to stunting in children. Their presence across the food system and in breast milk is concerning, thus warranting further research to replicate and expand on our findings and to understand implications for maternal and child health.

Survey of Aflatoxin M1 in Commercial Liquid Milk Products in China

ABSTRACT

The objective of this study was to investigate the occurrence of aflatoxin M1 (AFM1) in Chinese liquid milk products. A total of 190 liquid milk samples, including 168 ultrahigh-temperature-treated milk samples and 22 pasteurized milk (PM) samples, were collected in August 2019. A screening assay with the Charm rapid test kit and a confirmation method with high-performance liquid chromatography were used for AFM1 analysis. Nine (4.74%) samples were screened positive, of which 5 (2.11%) samples were confirmed with concentration levels of 0.022 to 0.049 μg/kg. The AFM1 levels confirmed were all below the maximum residue levels set by China, the European Union, the United States, and the Codex Alimentarius Commission. The detection rate of AFM1 in domestic milk samples was 3.39%, while no AFM1 was detected in samples of imported milk. The prevalences of AFM1 detected in three groups of brands were as follows: group I, the major brands of China, 2.70%; group II, the local city domestic brands, 4.55%; and group III, the brands imported into China, 0. The detection rate of AFM1 was significantly higher in PM samples (9.09%) than in ultrahigh-temperature-treated samples (1.19%) (P < 0.05). Although the residue level of AFM1 did not exceed the maximum residue levels in any of the samples, the higher detection rate in local Chinese brands, especially in PM samples, deserves the attention of the Chinese government and consumers.

HIGHLIGHTS

Aflatoxin M1 in Africa: Exposure Assessment, Regulations, and Prevention Strategies - A Review

Aflatoxins are the most harmful mycotoxins causing health problems to human and animal. Many acute aflatoxin outbreaks have been reported in Africa, especially in Kenya and Tanzania. When ingested, aflatoxin B1 is converted by hydroxylation in the liver into aflatoxin M1, which is excreted in milk of dairy females and in urine of exposed populations. This review aims to highlight the AFM1 studies carried out in African regions (North Africa, East Africa, West Africa, Central Africa, and Southern Africa), particularly AFM1 occurrence in milk and dairy products, and in human biological fluids (breast milk, serum, and urine) of the populations exposed. Strategies for AFM1 detoxification will be considered, as well as AFM1 regulations as compared to the legislation adopted worldwide and the assessment of AFM1 exposure of some African populations. Egypt, Kenya, and Nigeria have the highest number of investigations on AFM1 in the continent. Indeed, some reports showed that 100% of the samples analyzed exceeded the EU regulations (50 ng/kg), especially in Zimbabwe, Nigeria, Sudan, and Egypt. Furthermore, AFM1 levels up to 8,000, 6,999, 6,900, and 2040 ng/kg have been reported in milk from Egypt, Kenya, Sudan, and Nigeria, respectively. Data on AFM1 occurrence in human biological fluids have also shown that exposure of African populations is mainly due to milk intake and breastfeeding, with 85-100% of children being exposed to high levels. Food fermentation in Africa has been tried for AFM1 detoxification strategies. Few African countries have set regulations for AFM1 in milk and derivatives, generally similar to those of the Codex alimentarius, the US or the EU standards.

Aflatoxin M1 prevalence in breast milk in Morocco: Associated factors and health risk assessment of newborns "CONTAMILK study"

The aim of this study was to assess the contamination of breast milk by aflatoxin M1 among nursing mothers from Rabat, Morocco, and to explore its association with several maternal parameters and dietary habits. In addition, the health risk assessment of the newborns by the estimation of the daily intake. A competitive Enzyme Linked Immunosorbent Assay method was used for the analysis of aflatoxin M1 in breast milk samples. Analytical results indicate that out of 82 total samples, 43 samples (52.4%) of milk were positive. Aflatoxin M1 levels ranged from undetectable to 13.33 ng/L, while the mean level was 5.75 ± 3.44 ng/L. Besides, several factors and foodstuffs seem to increase the level of AFM1 in breast milk. As regards the estimated daily intake of aflatoxin M1, it varies between immeasurable and a maximum of 1.16 ng/kg.bw. The degree of exposure to AFB1 and the levels of its metabolite AFM1 in breast milk were low, compared to some studies from other countries. Further investigations and periodic monitoring programs are recommended in large samples and in many cities of morocco to assess the level of exposure of the Moroccan population.

Aflatoxin M1 contamination level in Iranian milk and dairy products: a systematic review and meta-analysis

Aflatoxin M1 is a derivate of aflatoxin B1 and an important contaminant of milk and dairy products. This systematic review and meta-analysis was conducted on relevant Persian and English original articles in national and international databases with no time limits until 1 January 2018. In total 605 articles were found among which 70 articles met the inclusion criteria for meta-analysis. The prevalence (95% confidence interval (CI)) and mean concentration (95% CI) of aflatoxin M1 was found to be 64% (53-75%) and 39.7 ng/l (31.9-47.4 ng/l) in raw milk, 95% (89-98%) and 62.3 ng/l (40.6-84 ng/l) in pasteurised milk, 71% (56-84%) and 60.1 ng/l (30.9-89.3 ng/l) in sterilised milk, 59% (20-93%) and 5.5 ng/l (3.3-7.7 ng/l) in breast milk and 72% (61-81%) and 82.3 ng/kg (63.7-100.9 ng/kg) in dairy products. In general, 9% (4-16%) of milks and 10% (4-17%) of dairy products had aflatoxin M1 in concentrations exceeding the permitted level of Iranian standards (500 ng/l). Based on the maximum permitted aflatoxin M1 concentration in standards of Europe (50 ng/l), these percentages increase to 25% (18-32%) for milks and 18% (9-29%) for dairy products. According to the results, further control and preventive measures should be applied on livestock feeds because decreased aflatoxin B1 contamination at this level results in decreased aflatoxin M1 in milk and dairy products.

Contamination level and exposure assessment to Aflatoxin M1 in Jordanian infant milk formulas

Aflatoxin M1 (AFM1) is a principal hydroxylated-aflatoxin B1 (AFB1) metabolite, and has been classified as possible human carcinogen (group 2B). The aim of this study was to survey the contamination level, estimated daily intake (EDI) and tolerable daily intake % (TDI%) of AFM1 in Jordanian infant milk formulas. A total of 120 samples, 48 starter and 72 follow-on formula samples were collected and analyzed using ELISA technique. Of the 120 surveyed samples, 58 (48.33%) were AFM1-positive and exceeded the EU maximum limit for AFM1 in IMF (25 ng/kg). The average AFM1 concentration was 69.93 and 84.78 ng AFM1/kg, with range of <5 - 89.25 and <5 - 213.84 ng AFM1/kg in starter and follow-on formula, respectively. It is also noteworthy the high EDI of AFM1 by infants (1.557 and 1.551 ng AFM1/kg b.w./day), and the high TDI% values (786.9 and 775.9%). In addition, current study indicated high-extrapolated AFB1 content in the feed; accordingly, raised the need to implement good agricultural and hygienic practices as preventive and controlling measures to decrease AFM1 in milk and IMF through controlling AFB1 in feed at the farm level. Finally, it is obvious that the contamination of IMF by AFM1 is an international problem, and the protection of infants and young children against AFM1 in Jordan requires a fundamental setup of clear legal limits of AFM1 in Jordanian standards and strict monitoring and continual analysis of IMF traded and consumed in Jordan.

Concentration and Prevalence of Aflatoxin M1 in Human Breast Milk in Iran: Systematic Review, Meta-Analysis, and Carcinogenic Risk Assessment: A Review

This meta-analysis was designed to review the published reports regarding the concentration and/or prevalence of aflatoxin M₁ (AFM₁) in human breast milk in Iran. The carcinogenic risk for Iranian infants consuming this milk was estimated with the hazard index. The PubMed and Scopus databases and the Scientific Information Database were screened for relevant studies between 1995 and 2017, and 11 of the 112 collected studies were included in the systematic review and meta-analysis. The mean (95% confidence interval) concentration of AFM₁ was 5.85 ng/L (4.54 to 7.15 ng/L), which was lower than the European Union standard (25 ng/L). The mean prevalence of AFM₁ in breast milk in Iran was 42% (11 to 77%). The estimated daily intakes for male and female infants were 0.02 to 5.57 ng/kg and 0.02 to 3.68 ng/kg of body weight per day, respectively. The rank order of estimated daily intake for both male and female infants according to age was 1 week > 1 month > 6 months > 12 months. The hazard index for all age groups of infants in all provinces in Iran was less than 1. Therefore, infants in Iran were not considered at carcinogenic risk from AFM₁ in human breast milk.

Human milk mycotoxin contamination: smoking exposure and breastfeeding problems

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

Application of a LC-MS/MS method for multi-mycotoxin analysis in infant formula and milk-based products for young children commercialized in Southern Brazil

An analytical method based on liquid chromatography-tandem mass spectrometry (LC-MS/MS) was validated and applied for the analysis of aflatoxin M₁ (AFM₁), ochratoxin A (OTA) and deoxynivalenol (DON) in infant formula and milk-based products for young children commercialized in Brazil. A total of 38 samples were evaluated, including 12 infant formula, 14 follow-on formula and 12 samples of milk-based products. AFM₁ was detected in 12 (32%) samples, and seven (18%) samples contained AFM₁ levels above the method limit of quantification in a concentration range between 0.013 and 0.067 ng mL^-1 (0.026 ± 0.019). Two samples of milk-based products exceeded the maximum level (ML) fixed by the European Union for AFM₁ in baby foods, however, all samples were in agreement with the levels established by the Brazilian regulation. OTA and DON were not detected in any of the analyzed samples.

Multiple mycotoxin exposure of infants and young children via breastfeeding and complementary/weaning foods consumption in Ecuadorian highlands

The dietary exposure to mycotoxins in Ecuadorian children aged 0-23 months (320 rural and 603 urban) was evaluated based on the intake of breast milk and staple cereals used as complementary/weaning foods. A probabilistic distribution approach by first order Monte Carlo simulation was adopted to assess the locally occurring mycotoxins (aflatoxins M₁ and B₁ in breast milk, ochratoxin A and deoxynivalenol in wheat noodles and oat flakes, and HT-2 toxin in polished rice). Overall, exposure was modest but higher for rural children due to their monotonous diet. Aflatoxin exposure by breast milk intake were of health concern in both areas (Margin of Exposure and Combined Margin of Exposure Index<10,000). Mycotoxin exposure by staple cereals intake was considered tolerable across feeding stages for individual mycotoxin-cereal combination (Hazard Quotient<1) and combined exposure (Hazard Index<1). The major exposure was to HT-2 toxin by rice intake at complementary feeding (15% rural and 4% urban above TDI) and at weaning stage (26% rural and 6% urban above TDI). Since the usual Ecuadorian diet is based on the same staple cereals, risk management actions could lead to a better protection of young children and also ensure higher safety of the recommended breastfeeding practices by protecting nursing mothers.

Assessment of Mycotoxin Exposure in Breastfeeding Mothers with Celiac Disease

OBJECTIVE

To assess the risk of mycotoxin exposure (aflatoxin M1, ochratoxin A, and zearalenone) in celiac disease (CD) breastfeeding mothers and healthy control mothers, as well as in their offspring, by quantifying these contaminants in breast milk.

STUDY DESIGN

Thirty-five breastfeeding women with CD on a gluten-free diet and 30 healthy breastfeeding controls were recruited. Milk sampling was performed three times per day for three consecutive days. Mycotoxin content was investigated by an analytical method using immunoaffinity column clean-up and high-performance liquid chromatography (HPLC) with fluorometric detection.

RESULTS

Aflatoxin M1 (AFM1) was detected in 37% of CD group samples (mean ± SD = 0.012 ± 0.011 ng/mL; range = 0.003-0.340 ng/mL). The control group showed lower mean AFM1 concentration levels in 24% of the analyzed samples (0.009 ± 0.007 ng/mL; range = 0.003-0.067 ng/mL, ANOVA on ranks, p-value < 0.01). Ochratoxin A and zearalenone did not differ in both groups.

CONCLUSION

Breast milk AFM1 contamination for both groups is lower than the European safety threshold. However, the estimated exposures of infants from CD mothers and control mothers was much higher (≃15 times and ≃11 times, respectively) than the threshold set by the joint FAO/WHO Expert Committee on Food Additives (JECFA). Since incongruities exist between JECFA and the European Union standard, a novel regulatory review of the available data on this topic is desirable. Protecting babies from a neglected risk of high AFM1 exposure requires prompt regulatory and food-control policies.

Achievements and Prospects in Electrochemical-Based Biosensing Platforms for Aflatoxin M₁ Detection in Milk and Dairy Products

Aflatoxins, which are mainly produced by Aspergillus flavus and parasiticus growing on plants and products stored under inappropriate conditions, represent the most studied group of mycotoxins. Contamination of human and animal milk with aflatoxin M₁, the hydroxylated metabolite of aflatoxin B₁, is an important health risk factor due to its carcinogenicity and mutagenicity. Due to the low concentration of this aflatoxin in milk and milk products, the analytical methods used for its quantification have to be highly sensitive, specific and simple. This paper presents an overview of the analytical methods, especially of the electrochemical immunosensors and aptasensors, used for determination of aflatoxin M₁.

Aflatoxin M1 in human breast milk in southeastern Turkey

This study was performed to determine aflatoxin M₁ (AFM₁) in human breast milk samples collected in Şanlıurfa, located in Southeastern region of Turkey, and to investigate a possible correlation between AFM₁ occurrence (frequency and levels) and sampling seasons. Human breast milk samples collected in December 2014 and in June 2015 from a total of 74 nursing women, both outpatient and inpatient volunteers in hospitals located in Şanlıurfa, Turkey, were analyzed using competitive enzyme-linked immunosorbent assay (ELISA) for the presence of AFM₁. AFM₁ was detected in 66 (89.2%) out of 74 samples at an average concentration of 19.0 ± 13.0 ng/l (min.-max., 9.6-80 ng/l). There was a statistically significant difference between December and June concerning AFM₁ levels (p < 0.05). Further detailed studies will be needed to determine the main sources of aflatoxins in food, to establish protection strategies against maternal and infant exposure to these mycotoxins.

The Nickel Concentration in Breast Milk during the First Month of Lactation in Yazd, Center of Iran

Breastfeeding plays an important role in the growth and development of breastfed infants, especially in the first 6 months of their lives. The present study was conducted to determine the nickel concentrations in breast milk of lactating women in Yazd, Iran. One hundred fifty volunteers were selected among nursing mothers referring to health centers in Yazd. In the first month of lactation, milk samples were collected three times, on days 3 to 5 (first), 16 (Second), and 30 (third) after delivery. Nickel concentration of the samples was measured by atomic absorption spectrophotometer. Demographic variables were collected through a questionnaire which was completed by mothers. The mean age of the study group was 27.40 ± 4.66 years. The mean nickel concentrations in breast milk at the first, second, and third samples were 47.3 ± 7.40, 49.9 ± 8.05, and 54.8 ± 7.38 μg/l, respectively. The concentration of nickel in the breast milk of more than 86 % of mothers was higher than the permissible range for it. There was no significant relationship between the mean value of nickel in breast milk and education, age, and job of mothers. High level of nickel in breast milk may be attributed to consumed food and drinking water containing nickel. Monitoring the nickel level in breast milk regularly is recommended.

Exposure Assessment of Infants to Aflatoxin M₁ through Consumption of Breast Milk and Infant Powdered Milk in Brazil

Aflatoxin M₁ (AFM₁) is an important biomarker that can be used to evaluate aflatoxin exposure in both humans and animals. The aim of this study was to evaluate the exposure degree of infants to AFM₁ through consumption of breast milk and infant powdered milk in Brazil. For this purpose, the estimated daily intake (EDI) for infants was calculated based on the AFM₁ levels analyzed in 94 breast milk (BM) samples collected in Southern Brazil, and 16 infant powdered milk (IPM) samples commonly commercialized in Brazil. AFM₁ was detected in 5.3% (n = 5) and 43.8% (n = 7) of BM and IPM samples, with mean levels of 0.003 ng/g and 0.011 ng/g, respectively. All the IPM samples showed AFM₁ levels lower than those established by the Brazilian guidelines (5 ng/g), and in most of the samples (81.25%) levels were below the maximum limit tolerated by the European Commission (0.025 ng/g). The EDI of AFM₁ for infants aged zero to 12 months old showed values from 0.018 to 0.069 ng/kg body weight/day for BM, and 0.078 to 0.306 ng/kg body weight/day for IPM. Hazard index (HI) values for BM and IPM were less than one, except for IPM intended for infants up to one month. In conclusion, the exposure of infants to AFM₁ was low, but continuous monitoring of mycotoxin levels is essential to minimize infant health risk.

Aflatoxin M1 in milk and milk products: a short review

Aflatoxin M1 (AFM1) is associated with carcinogenicity, genotoxicity, mutagenicity, and teratogenicity and as a result, represents a human health problem worldwide. This review will detail the toxicity, analytical methodology, occurrence, and prevention and control of AFM1 in milk and milk products. The probable daily intakes (PDI) per bodyweight (bw) worldwide ranged from 0.002 to 0.26 ng/kg bw/day for AFM1. Nevertheless, the high occurrence of AFM1 demonstrated in this review establishes the need for monitoring to reduce the risk of toxicity to humans. The recommended extraction method of AFM1 from milk is liquid-liquid with acetonitrile because of the acceptable recoveries (85-97%), compatibility with the environment, and cleanest extracts. The recommended analytical technique for the determination of AFM1 in milk is the high performance-liquid chromatography-fluorescence detector (HPLC-FLD), achieving a 0.001 µg/kg detection limit. The HPLC-FLD is the most common internationally recognised official method for the analysis of AFM1 in milk. The suggested extraction and analytical method for cheese is dichloromethane (81-108% recoveries) and ELISA, respectively. This review reports the projected worldwide occurrence of AFM1 in milk of 2010-2015. Of the 7,841 samples, 5,873 (75%) were positive for AFM1, 26% (2,042) exceeded the maximum residue levels (MRL) of 0.05 µg/kg defined by the European Union and 1.53% (120) exceeded the MRL of 0.5 µg/kg defined by the US Food and Drug Administration. The most effective way of preventing AFM1 occurrences is to reduce contamination of AFB1 in animal feed using biological control with atoxigenic strains of Aspergillus flavus, proper storage of crops, and the addition of binders to AFB1-contaminated feed. Controllable measures include the addition of binders and use of biological transforming agents such as lactic acid bacteria applied directly to milk. Though the one accepted method for the control of AFM1 in milk and milk products is the enforcement of governmental MRL.

Exposure of Infants to Aflatoxin M1 from Mother's Breast Milk in Ilam, Western Iran

Objectives

Aflatoxins as a highly toxic group of mycotoxins are present in the environment and foodstuff. These have been reported to cause serious health problems in humans. Since aflatoxin M1 (AFM1) is excreted into breast milk, investigating the exposure of infants to AFM1 is of special concern.

Methods

In the present study, breast milk samples were collected from 85 lactating mothers in Ilam province, Iran, and the levels of AFM1 were analyzed using the enzyme-linked immunosorbent assay-based technique. AFM1 was detected in breast milk of all lactating women. The mean contamination level was 5.91 ± 2.031 ng/L, ranging from 2 ng/L to 10 ng/L.

Results

Multiple regression analysis indicated no significant associations of consumption of milk and dairy products, meat, fish, legumes, grain products, fruits, and nuts with the concentration of AFM1 in breast milk. Furthermore, no significant association was observed between AFM1 concentration and anthropometric data of infants.

Conclusion

In western parts of Iran, lactating mothers and their infants could be at risk of aflatoxin B1 and AFM1 exposure, respectively. Therefore, in Iran, the evaluation of AFM1 in human breast milk as a biomarker for postnatal exposure of infants to this carcinogen requires more attention in different regions and various seasons.

An overview on mycotoxin contamination of foods in Africa

Mycotoxins are fungal secondary metabolites that contaminate various feedstuffs and agricultural crops. The contamination of food by mycotoxins can occur before production, during storage, processing, transportation or marketing of the food products. High temperature, moisture content and water activity are among the predisposing factors that facilitate the production of mycotoxins in food. Aflatoxins, ochratoxins, fumonisins, deoxynivalenol and zearalenone are all considered the major mycotoxins produced in food and feedstuffs. In Africa, mycotoxin contamination is considered to be a major problem with implications that affect human and animal health and economy. Aflatoxin-related hepatic diseases are reported in many African countries. Ochratoxin and fumonisin toxicity in humans and animals is widespread in Africa. The available, updated information on the incidence of mycotoxin contamination, decontamination and its public health importance in Africa is lacking. The aim of this review is to highlight, update and discuss the available information on the incidence of mycotoxins in African countries. The public health implications and the recommended strategies for control of mycotoxins in food and agricultural crops are also discussed.

Association between aflatoxin M1 exposure through breast milk and growth impairment in infants from Northern Tanzania

Infants breastfeeding from mothers consuming aflatoxin contaminated foods may be exposed to aflatoxin M1 (AFM1), a metabolite of aflatoxin B1. This study estimated the association between AFM1 exposure levels and growth indicators, for infants under six months of age in the Rombo district in Northern Tanzania. A total of 143 infants and their mothers were involved. Breast-milk samples, infants' anthropometric data and 24 h dietary recall for mothers were taken at the 1st, 3rd and 5th months of children age. AFM1 contaminations in the samples were determined using HPLC. Aflatoxin M1 exposure by an infant was estimated by multiplying contamination in the breast milk consumed by him/her with the breast milk intake recorded by the United States Environmental Protection Agency for infants of his/her age divided by the infant's body weight. All the breast-milk samples were contaminated by AFM1 at levels ranging from 0.01 to 0.55 ng/ml. Above 90% of samples exceeded the EU limit of 0.025 ng/ml for infants' foods while over 76% exceeded the EU limit of 0.05 ng/ml for dairy milk and milk products. Only 1% of the samples exceeded the limit of 0.5 ng/ml set for dairy milk in the United States and several countries in Asia. AFM1 Exposures ranged from 1.13-66.79 ng/kg body weight per day. A small but significant (P<0.05) inverse association was observed between AFM1 exposure levels and weight for age Z-score or height for age Z-score. Appropriate strategies should be applied to minimise aflatoxin B1 exposure in lactating mothers in order to protect infants from AFM1 exposure.

The molecular epidemiology of chronic aflatoxin driven impaired child growth

Aflatoxins are toxic secondary fungal metabolites that contaminate dietary staples in tropical regions; chronic high levels of exposure are common for many of the poorest populations. Observations in animals indicate that growth and/or food utilization are adversely affected by aflatoxins. This review highlights the development of validated exposure biomarkers and their use here to assess the role of aflatoxins in early life growth retardation. Aflatoxin exposure occurs in utero and continues in early infancy as weaning foods are introduced. Using aflatoxin-albumin exposure biomarkers, five major studies clearly demonstrate strong dose response relationships between exposure in utero and/or early infancy and growth retardation, identified by reduced birth weight and/or low HAZ and WAZ scores. The epidemiological studies include cross-sectional and longitudinal surveys, though aflatoxin reduction intervention studies are now required to further support these data and guide sustainable options to reduce the burden of exposure. The use of aflatoxin exposure biomarkers was essential in understanding the observational data reviewed and will likely be a critical monitor of the effectiveness of interventions to restrict aflatoxin exposure. Given that an estimated 4.5 billion individuals live in regions at risk of dietary contamination the public health concern cannot be over stated.

Multi-mycotoxin determination in baby foods and in vitro combined cytotoxic effects of aflatoxin M1 and ochratoxin A

The co-occurrence of mycotoxins in baby foods, including aflatoxin M1 (AFM1) and ochratoxin A (OTA), has been reported in previous studies, but data on their potential combined toxic effects are still missing. The present work aimed at (1) validating an in-house multi-mycotoxin high performance liquid chromatography with fluorescence detection (HPLC-FLD) method for AFM1, total aflatoxins (aflatoxin B1 (AFB1), aflatoxin B2 (AFB2), aflatoxin G1 (AFG1), aflatoxin G2 (AFG2)) and OTA in infant formulae (milk powders) and cereal baby foods (flours), and (2) assessing the combined cytotoxic effects of AFM1 and OTA in an intestine-derived cell line. The HPLC-FLD method, which included a chloroform extraction, liquid-liquid extraction, immunoaffinity column clean-up and fluorescence detection after post-column derivatisation with electrochemically generated bromine, was adequate for the analysis of baby foods and met the requirements of validation and quality control for the studied working ranges. The limits of quantification for AFM1, AFB1, AFB2, AFG1, AFG2 and OTA were 0.069, 0.032, 0.020, 0.047, 0.020 and 0.244 μg/kg, respectively. The mean recovery values were 96, 114, 112, 107, 101 and 87%, respectively. A dose-dependent cytotoxicity was observed for individual and combined AFM1 and OTA using the Caco-2 cell line, which represents a site of contact of both mycotoxins in the body, after oral exposure. Interactions between both mycotoxins were disclosed by application of the concentration addition (CA) and independent action (IA) models, revealing the predominance of an antagonistic pattern. In conclusion, this study proposes a HPLC-FLD method for multi-mycotoxin monitoring in baby foods and provides evidence for the interaction between AFM1 and OTA, and for the applicability of CA/IA models to predict the effect of mycotoxins mixtures, further contributing to the prevention of mycotoxins-associated adverse health effects.

Developments in mycotoxin analysis: an update for 2011-2012

This review highlights developments in mycotoxin analysis and sampling over a period between mid-2011 and mid- 2012. It covers the major mycotoxins aflatoxins, Alternaria toxins, ergot alkaloids, fumonisins, ochratoxin, patulin, trichothecenes, and zearalenone. A section on mycotoxins in botanicals and spices is also included. Methods for mycotoxin determination continue to be developed using a wide range of analytical systems ranging from rapid immunochemical-based methods to the latest advances in mass spectrometry. This review follows the format of previous reviews in this series (i.e. sections on individual mycotoxins), but due to the rapid spread and developments in the field of multimycotoxin methods by liquid chromatography-tandem mass spectrometry, a separate section has been devoted to advances in this area of research.

Quality and safety aspects of infant nutrition

Quality and safety aspects of infant nutrition are of key importance for child health, but oftentimes they do not get much attention by health care professionals whose interest tends to focus on functional benefits of early nutrition. Unbalanced diets and harmful food components induce particularly high risks for untoward effects in infants because of their rapid growth, high nutrient needs, and their typical dependence on only one or few foods during the first months of life. The concepts, standards and practices that relate to infant food quality and safety were discussed at a scientific workshop organized by the Child Health Foundation and the Early Nutrition Academy jointly with the European Society for Paediatric Gastroenterology, Hepatology and Nutrition, and a summary is provided here. The participants reviewed past and current issues on quality and safety, the role of different stakeholders, and recommendations to avert future issues. It was concluded that a high level of quality and safety is currently achieved, but this is no reason for complacency. The food industry carries the primary responsibility for the safety and suitability of their products, including the quality of composition, raw materials and production processes. Introduction of new or modified products should be preceded by a thorough science based review of suitability and safety by an independent authority. Food safety events should be managed on an international basis. Global collaboration of food producers, food-safety authorities, paediatricians and scientists is needed to efficiently exchange information and to best protect public health.