Infant formula preparation, handling, and related practices in the United States

Infant formula fatty acid profile following microwave heating

Microwave heating of foods may alter their content. Yet, parents commonly heat infant formula in the microwave oven. The study aimed at understanding whether microwave heating of formula changes its fatty acid (FA) composition. Portions of infant formula were prepared and divided in three parts: control (sampled twice: at the start and after 30 minutes), microwave (sampled twice: after reaching 37°C and 50°C), and water bath (sampled twice: after reaching 37°C and 50°C). In thus obtained samples, a total profile of 25 FA was assessed using gas chromatography-mass spectrometry. Overall, fourteen portions were prepared, which were sampled 84 times yielding 2075 individual total FA level measurements. Few differences were identified between the microwave, control, and water bath groups. Microwave warming to 37°C was associated with increases of C12 (median increased by +0.40%, p = 0.0063), C14 (+0.05%, p = 0.0091), and C4 content (+6.90%, p = 0.0131). Microwaving up to 50°C slightly decreased C16:1trans (-5.00%, p = 0.0463) and C18:2trans1 (-5.13%, p = 0.0231). A paired comparison of pooled control and microwaved samples revealed increases in C12 (+0.18%, p = 0.0490) as well as a loss of C18:2trans1 (also -5.13%, p = 0.0073) and C18:2trans3 (-5.56%, p = 0.0042) after microwave treatment. C18:2trans1 (-2.63%, p = 0.0132) and C18:3trans1 (-2.26%, p = 0.0434) were lower in microwaved samples compared with the water bath. A slightly lower C18:2 content was found in the water bath samples than in the control groups (-0.11%, p = 0.0430). None of these differences would remain significant after a correction for multiple comparisons. Microwave heating of infant formula to 37°C or 50°C might marginally alter its total FA profile. Further studies are required to determine whether it alters the rate of free radical formation.

Health Impacts of Early Complementary Food Introduction Between Formula-fed and Breastfed Infants

BACKGROUND

Global health agencies agree that infants should not be fed complementary foods before 4 to 6 months of age. However, given the World Health Organization (WHO) definition of complementary food as "anything other than breast milk," little is known about the relative risks of formula compared with other complementary foods on infant health. This article aims to fill this gap in the literature, by assessing how differences in the timing of the introduction of nonformula complementary food between breastfed and formula-fed infants impacts infant health.

METHODS

Eight health outcomes by complementary food introduction, breast-feeding, formula feeding, and mixed feeding (breastfed and formula-fed) were predicted using logistic regression with generalized estimating equations on the newborn through 6-month waves of the Infant Feeding Practices Study II (IFPS-II).

RESULTS

Complementary foods increased the likelihood for all health risks measured. Given greater prevalence of early complementary food introduction among formula-fed infants, most health differences between breast-feeding groups shift to nonsignificance in full models, with the exception of higher rates of hard stool and cough/wheeze among formula-fed and mixed-fed infants but lower rates of diarrhea (LO = -0.577; 95% confidence interval [CI] = -1.074 to 0.080) and runny nose or cold (LO = -3.19; 95% CI = -0.552 to -0.086) for mixed-fed than breastfed infants.

CONCLUSIONS

Our results confirm health benefits of exclusive breast-feeding and that the introduction of complementary foods before 4 to 6 months poses a greater risk to infant health than does formula. Greater attention to the early introduction of complementary foods is needed in research and clinical practice.

Underestimated Risks of Infantile Infectious Disease from the Caregiver's Typical Handling Practices of Infant Formula

The impact on infant caregiver as a reservoir of pathogens has not been exploited with perspective to powdered infant formula (PIF). Here we reveal novel route of pathogen transfer through hand-spoon-PIF unexpectedly occurred by even typical practices of caregivers, handling of PIF and storage of feeding-spoon in PIF container. Hand-spoon-PIF contamination route was simulated to analyze the transfer and subsequent survival of pathogens. Major pathogens associated with infantile fatal diseases (Cronobacter sakazakii, Salmonella enterica, Staphylococcus aureus) were readily transmitted to PIF from skin (3−6 log CFU/hand) via spoons following long-term survival of transferred pathogens (3 weeks; use-by date of PIF) as the excessive level of infectious dose, highlighting direct onset of diseases. Low bacterial load on skin (ca. 1 log CFU/hand) could prevent cross-contamination of PIF, however, at least 72 h survival of transferred pathogen on spoons demonstrated the probability on re-contamination of PIF. To our knowledge, this is the first study to investigate the cross-contamination of utensils in contact with powdered-foods. Bacterial load on hands is the key determinant of pathogen transfer and the extent of risk are species-dependent. These evidential results redefine risk of caregivers’ practices and facilitate incorporation of cross-contamination into risk-assessment as underestimated route of infection.

Infant Exposure to Metals through Consumption of Formula Feeding in Mekelle, Ethiopia

This study aimed at determination of heavy metals (cadmium, lead, and zinc) in milk-based infant formulas collected from Mekelle, Ethiopia, and their associated health risks to the infants through consumption of these products. The infant feeding samples were dry-ashed in a muffle furnace followed by digestion in nitric acid and the resulting solutions were analyzed by flame atomic absorption spectrophotometer. Cadmium was not detected in the samples while the levels of lead and zinc ranged from not detected value to 0.103 mg/kg and from 27.888 to 71.553 mg/kg, respectively. The estimated daily intake values and the health risk indices of both metals were below their respective safety limits and the threshold of 1, respectively. These findings show low infant health risk of these metals through consumption of these products. Nevertheless, regular monitoring of infant formula for toxic metals is required since infants are potentially more susceptible to metals.

Observations and Conversations: Home Preparation of Infant Formula Among a Sample of Low-Income Mothers in the Southeastern US

OBJECTIVE

Explore infant formula preparation attitudes and beliefs among low-income, formula-feeding, Southeastern US mothers.

DESIGN

Cross-sectional study using in-home observations and in-depth interviews.

SETTING

Participant homes.

PARTICIPANTS

Thirteen low-income mothers of normal birth weight, healthy, term infants aged ≤3 months, who were predominantly feeding powdered or from-concentrate formula.

VARIABLES MEASURED

Reading formula preparation instructions; order of added ingredients; leveling powdered formula scoop(s); adding cereal or other ingredients to bottles.

PHENOMENON OF INTEREST

Perceptions of formula preparation or manipulation.

ANALYSIS

Descriptive statistics described sample characteristics and home observation variables. Thematic analysis of in-depth interviews revealed the following major themes: formula preparation can be intimidating; expressions of complex heuristic perceptions about formula preparation; cost and convenience motivate maternal behaviors; and infant cues override recommendations. Data from qualitative and quantitative activities were triangulated.

RESULTS

Behaviors, including improper reconstitution and modifications/additions to prepared formula (eg, infant cereal) were observed during home observations and/or described during in-depth interviews. Inconsistencies were detected between observed behaviors (eg, adding too much water to the bottle) and those reported during in-depth interviews (eg, stating over-dilution could be detrimental to the infant's health).

CONCLUSIONS AND IMPLICATIONS

Targeting knowledge or skills gaps and behavioral motivators in the formula-feeding population could positively affect infant-feeding practices that occur outside of recommendations.

Infant food applications of complex carbohydrates: Structure, synthesis, and function

Professional health bodies such as the World Health Organization (WHO), the American Academy of Pediatrics (AAP), and the U.S. Department of Health and Human Services (HHS) recommend breast milk as the sole source of food during the first year of life. This position recognizes human milk as being uniquely suited for infant nutrition. Nonetheless, most neonates in the West are fed alternatives by 6 months of age. Although inferior to human milk in most aspects, infant formulas are able to promote effective growth and development. However, while breast-fed infants feature a microbiota dominated by bifidobacteria, the bacterial flora of formula-fed infants is usually heterogeneous with comparatively lower levels of bifidobacteria. Thus, the objective of any infant food manufacturer is to prepare a product that results in a formula-fed infant developing a breast-fed infant-like microbiota. The goal of this focused review is to discuss the structure, synthesis, and function of carbohydrate additives that play a role in governing the composition of the infant microbiome and have other health benefits.

Essential and toxic elements in commercial baby food on the Spanish and Serbian market

About 10 heavy elements were determined in 90 samples of baby food collected from Spanish and Serbian market. The results indicated that iron, manganese and copper were most frequently detected. Tin was the predominant toxic element in both Spanish and Serbian samples, with occurrence frequencies of 12.5% and 10.0%, respectively. Element intake for Spanish and Serbian infants were estimated and compared with the recommended reference values, for the majority of elements being lower than one. However, iron and manganese intake through consumption of infant/follow-on formulas were assessed to be higher than the respective daily intakes. Particular attention should be paid to the exposure of infants who consume porridges made of vegetables and fish or chicken, because they may ingest certain elements, particularly arsenic and lead, at levels that exceed the reference toxicological values. Principal component analysis (PCA) was applied to classify and distinguish the different types of baby food.

MicroRNAs in Breastmilk and the Lactating Breast: Potential Immunoprotectors and Developmental Regulators for the Infant and the Mother

Human milk (HM) is the optimal source of nutrition, protection and developmental programming for infants. It is species-specific and consists of various bioactive components, including microRNAs, small non-coding RNAs regulating gene expression at the post-transcriptional level. microRNAs are both intra- and extra-cellular and are present in body fluids of humans and animals. Of these body fluids, HM appears to be one of the richest sources of microRNA, which are highly conserved in its different fractions, with milk cells containing more microRNAs than milk lipids, followed by skim milk. Potential effects of exogenous food-derived microRNAs on gene expression have been demonstrated, together with the stability of milk-derived microRNAs in the gastrointestinal tract. Taken together, these strongly support the notion that milk microRNAs enter the systemic circulation of the HM fed infant and exert tissue-specific immunoprotective and developmental functions. This has initiated intensive research on the origin, fate and functional significance of milk microRNAs. Importantly, recent studies have provided evidence of endogenous synthesis of HM microRNA within the human lactating mammary epithelium. These findings will now form the basis for investigations of the role of microRNA in the epigenetic control of normal and aberrant mammary development, and particularly lactation performance.

Are we adequately providing support services for optimal infant nutrition in Australia? A study in regional NSW

Evidence from the literature suggests that parents of infants in Australia may not be receiving appropriate professional assistance to support best practice in infant feeding. This study aimed to investigate whether services for infant nutrition (including breastfeeding, infant formula feeding and support for at-risk infants) complied with current recommendations. Relevant services in a regional area of NSW completed a questionnaire to characterise the assistance they provided for parents of infants in the first 6 months of life. Services for breastfeeding, unlike services for use of infant formula, were consistent with recommendations in the literature. Services were significantly more likely to provide education (χ2 (1, n = 44) = 5.939, P < 0.025) and various forms of professional support (χ2 (1, n = 44) = 20.29, P < 0.0001) for breastfeeding compared with infant formula. At-risk infants were mostly identified through growth monitoring, and extra support services were mostly provided on site. Parents of at-risk infants were encouraged to attend services; strategies included involving family in consultations, offering multiple services on site, free services and home visits. Other important measures recommended in the literature, such as providing continuous care from the antenatal period and transport, were provided infrequently.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS AND IMPLICATIONS

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

Home-made feeding bottles have inadequacies in their nutritional composition regardless of socioeconomic class

Fifty-four and fifty samples of home-prepared feeding bottles for infants from a public health unit (low socioeconomic group, LSG) and from a private pediatric clinic (high socioeconomic group, HSG), respectively, were chemically analyzed, and their energy, macronutrient and iron contents were compared with the standard composition recommended for follow-up formulas. Cow's milk and sucrose and cereals added to the bottles were largely used in the study. Energy, protein and carbohydrate contents were higher than the recommended level in 75.9, 27.7 and 81.5% of LSG samples and 62.0, 48.0 and 34.0% of HSG samples, respectively. Fat content was lower than the recommended level in 83.3% of LSG and 58.0% of HSG samples. Excessive values of energy, carbohydrates and protein, low fat content and macronutrient imbalance were found regardless of the socioeconomic class, thus indicating the need to improve the domestic feeding bottles' preparation practices and discourage the use of cow's milk and the addition of other ingredients.

Are our babies hungry? Food insecurity among infants in urban clinics

BACKGROUND

Food insecurity (FI) is common, but studies in families with infants are rare.

OBJECTIVES

To determine prevalence of FI, assess the effect public benefits have on FI, assess strategies to stretch nutritional resources (eg, using generic formula), and investigate FI's relationship to anthropometric measurements.

METHODS

A cross-sectional survey was completed. FI was classified using the US Department of Agriculture's 6-item indicator set.

RESULTS

A convenience sample of 144 infant caregivers was surveyed. Thirty-one percent endorsed FI. FI was more common among those receiving WIC and SNAP (39% vs 22%; P < .05). Fifteen percent stretched infant formula (27% FI vs 9% food secure; P < .01), 58% would not use generic formula, and 50% believed that generic and brand name formulas were not equivalent. There was no significant association between FI and anthropometric measurements.

CONCLUSIONS

FI and formula stretching were common, even among families receiving public benefits. Many families were cautious about using generic formula.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A pilot study describing infant formula preparation and feeding practices

Foodborne illnesses pose a problem to all individuals but are especially significant for infants. This observational study collected pilot data on formula preparation practices of 15 mothers of infants under the age of 7 months. A site survey tool was developed, based upon existing instruments. A trained observer traveled to the participants' homes to observe formula preparation and feeding. Some 73% of women did not wash their hands before preparing formula, 60% did not keep the prepared bottle cool during transport away from home, 53% checked the formula expiration date, 20% of infants slept with their bottle, 47% added cereal to formula, and 36% obtained information about formula preparation from a health professional. Hand washing is one of the most important home hygiene practices; however, hand washing practices by participants in our study prior to baby bottle preparation was poor.

Infant formula-handling education and safety

OBJECTIVES

Our goal was to assess the extent to which mothers learn about proper handling of infant formula from health professionals and package labels; mothers' beliefs about the likelihood of germs being in infant formula and the importance of following safe-use directions; whether they take measures while handling infant formula to prevent foodborne illnesses and injury to their infants; and maternal characteristics associated with unsafe infant formula-handling practices.

PARTICIPANTS AND METHODS

The study cohort consisted of mothers participating in the 2005-2007 Infant Feeding Practices Study II who fed their infant formula. We conducted frequency and multiple logistic regression analyses. Sample sizes for the analyses ranged from 860 to 1533.

RESULTS

The majority of formula-feeding mothers did not receive instruction on formula preparation (77%) or storage (73%) from a health professional. Thirty percent did not read some of the safe-use directions on the formula package label; an approximately equal percentage (38%) thought that both powdered (which is not sterile) and ready-to-feed (which is sterile) formula were unlikely to contain germs; and 85% believed that following safe-storage directions was very important. Among the mothers of the youngest infants analyzed, 55% did not always wash their hands with soap before preparing infant formula, 32% did not adequately wash bottle nipples between uses, 35% heated formula bottles in a microwave oven, and 6% did not always discard formula left standing for >2 hours. The prevalence of these unsafe practices was similar among mothers of older infants. No consistent pattern of maternal characteristics was associated with unsafe practices.

CONCLUSIONS

Many mothers do not follow safe practices when preparing infant formula. Additional research is needed to understand why more mothers do not follow safe formula-handling recommendations.

Infant Feeding Practices Study II: study methods

OBJECTIVE

Our goal is to describe the methods used in the Infant Feeding Practices Study II (IFPS II), a study of infant feeding and care practices throughout the first year of life. Survey topics included breastfeeding, formula and complementary feeding, infant health, breast-pump use, food allergies, sleeping arrangements, mother's employment, and child care arrangements. In addition, mothers' dietary intake was measured prenatally and postnatally.

PARTICIPANTS AND METHODS

The IFPS II sample was drawn from a nationally distributed consumer opinion panel of 500,000 households. All questionnaires were administered by mail, 1 prenatally and 10 postpartum. Qualifying criteria were used to achieve the sample goals of mothers of healthy term and late preterm singleton infants. In addition to the questionnaires about the infants, women were sent a diet-assessment questionnaire prenatally and at approximately 4 months after delivery; this questionnaire was also sent to members of a comparison group who were neither pregnant nor postpartum.

RESULTS

A sample of 4902 pregnant women began the study, and approximately 2000 continued through their infant's first year. Response rates ranged from 63% to 87% for the different questionnaires. Compared with adult mothers of singletons from the nationally representative sample of the National Survey of Family Growth, IFPS II participants had a higher mean education level; were older; were more likely to be middle income, white, and employed; were less likely to smoke; and had fewer other children. Compared with women who participated in the National Immunization Survey who gave birth in 2004, IFPS II mothers were more likely to breastfeed and to breastfeed longer.

CONCLUSIONS

The IFPS II provides a valuable database because of its large sample size, the frequency of its questionnaires, and its wide coverage of issues salient to infant feeding.

Food safety practices among pregnant women and mothers in the women, infants, and children program, Miami, Florida

Pregnant women and infants are two groups at the highest risk of severe outcomes from foodborne illnesses. We surveyed adult clients of a Women, Infants, and Children (WIC) clinic serving predominately African Americans in inner-city Miami, Florida, to assess food safety practices. Eligible and consenting women completed a 23-item self-administered survey with questions concerning food handling practices around the Partnership for Food Safety Education's Fight BAC! campaign constructs of "clean", "separate" (not cross-contaminated), "cook", and "chill". Of 342 eligible clients, 299 (87.4%) consented to participate. In general, the clients' food safety practices were most problematic in the cook and chill constructs. Using a cooking thermometer, refrigerating foods within 2 h, and thawing them safely were the least commonly reported safe practices. Women who were pregnant with their first child had the lowest food safety practice scores. Of the 62 pregnant participants, 32 (51.6%) reported eating hot dogs or deli meats without first reheating them some of the time or more often, and 22 (35.5%) reported eating soft cheeses and blue-veined cheeses some of the time or more often, putting the women at risk of listeriosis. Although all women in the WIC program could benefit from food safety education, these findings indicate that women during their first pregnancy should especially be targeted for food safety education.

Midwives in the UK: an exploratory study of providing newborn feeding support for postpartum mothers in the hospital

Our objective was to explore English midwives' views and experiences of supporting mothers with feeding their newborn baby. Grounded theory methodology was used. Data were collected using in-depth interviews from 30 midwives in the North of England. Data were analyzed using constant comparison techniques. Midwives were theoretically sampled for interview from a pool of volunteers recruited from a poster promoting the study in the clinical areas. Overall, hospital midwives felt that they did not have enough time to support mothers with feeding their neonate. To cope with these time constraints, midwives developed practices of rationing the time that they spent with mothers, and the rationing of resources available to mothers, to help them process mothers through the hospital services. These practices have important implications for the success of breastfeeding in hospitals as the practices by providers who are assigned to help breastfeeding initiation described here may inhibit the breastfeeding process.

Food safety beliefs and barriers to safe food handling among WIC program clients, Miami, Florida

OBJECTIVE

To determine beliefs about and barriers to good food safety practices among clients of a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program).

DESIGN

Five audiotaped focus groups.

SETTING

A large WIC Program clinic in Miami, Florida.

PARTICIPANTS

Thirty-two women attending the clinic who were demographically similar to clinic clients.

PHENOMENON OF INTEREST

Beliefs about, barriers to, and motivators for good food safety practices.

ANALYSIS

Focus groups were audiotaped and transcribed. Transcripts were independently analyzed by three researchers to identify recurring ideas within and between groups.

RESULTS

Participants did not perceive foodborne illnesses as a major problem or believe that foodborne illnesses usually resulted from poor food handling practices at home. The hardest practice to follow was using a cooking thermometer. Leaving perishable foods and baby bottles outside the refrigerator for longer than 2 hours were additional problems reported. Participants reported that their babies' health was the most important motivator to good food safety practices and that women may be most receptive to food safety education during their first pregnancy.

CONCLUSIONS AND IMPLICATIONS

WIC clients in this clinic have several deficiencies in their food safety knowledge and practices. The WIC Program may be well positioned to help its clients, particularly pregnant women, improve food safety practices.

Determination of macronutrients, by chemical analysis, of home-prepared milk feeding bottles and their contribution to the energy and protein requirements of infants from high and low socioeconomic classes

OBJECTIVES

To determine the macronutrients composition of home-prepared milk feeding bottles, by chemical analysis, and assess their contribution to the energy and protein requirements of children under two years of age from high (HSE) and low (LSE) socioeconomic classes.

METHODS

72 samples were analyzed for energy density and protein, fat and carbohydrate content: 41 from the LSE group and 31 from the HSE group. The assessment of the percentages of the energy and protein requirements met by the consumption of the milk bottles was calculated as follows: the energy and protein per 100 mL obtained through chemical analysis were multiplied by the volume consumed at each feeding, then by the number of feedings per day, the results divided by the energy and protein requirements and multiplied by 100. Energy and protein requirements were those recommended by the FAO/WHO/UNU Committee and the Food and Nutrition Board. The children's weight-for-age index was assessed.

RESULTS

Unmodified cow's milk was largely consumed by both groups. The addition of sugar and other ingredients to the milk was significantly higher in the LSE group. Moisture, protein and fat content were lower in the LSE group, whereas carbohydrate and energy content were higher. The percentages of energy and protein requirements provided by feeding bottles were higher in the LSE group. Children in the LSE group had lower z-scores for weight-for-age.

CONCLUSIONS

Differences in the preparation practices led to differences in the chemical results. The feeding bottles in the LSE group were high in energy, due to the addition of sugar and cereals to the milk in the bottle. The milk feeding bottles were an important weaning food providing more than 50% and 100% of the children's energy and protein requirements, respectively. The children's weight-for-age index was within the normal limits.