Antiinfective properties of human milk

Preparation and validation of a predictive model of breastfeeding initiation in the first hour of life

OBJECTIVE

The objective was to develop and validate a predictive model of initiation of breastfeeding in the first hour after delivery.

METHODS

Retrospective cohort study on women who gave birth between 2013 and 2018 in Spain. For data collection, an ad hoc questionnaire was designed to be filled in by the mothers, which was distributed to the different Spanish breastfeeding associations which, in turn, shared it with their associate partners. The development of the predictive model was made on a cohort of 3218 women (2/3) and was validated on a cohort of 1609 women (1/3). Mothers whose children were admitted to hospital at the time of birth were excluded. A multivariate analysis was performed by means of logistic regression, and predictive ability was determined by areas under the ROC curve (AUC).

RESULTS

81.0 % (2608) women started breastfeeding in the first hour in the derivation cohort, and 80.1 % (1289) in the validation cohort. The predictive factors in the final model were: the highest number of children and skin-to-skin contact at birth as flattering factors, while dystocic delivery reduced the likelihood of the onset of breastfeeding. The predictive ability (ROC AUC) in the derivation cohort was 0.89 (CI 95 %: 0.87-0.90), while in the validation cohort it was 0.89 (CI 95 %: 0.87-0.92).

CONCLUSIONS

This three-variable predictive model has excellent predictive ability in both the derivation cohort and the validation cohort. This model can identify women who are at high risk of non-initiating breastfeeding within the first hour after delivery.

Serum proteomics of mother-infant dyads carrying HLA-conferred type 1 diabetes risk

In-utero and dietary factors make important contributions toward health and development in early childhood. In this respect, serum proteomics of maturing infants can provide insights into studies of childhood diseases, which together with perinatal proteomes could reveal further biological perspectives. Accordingly, to determine differences between feeding groups and changes in infancy, serum proteomics analyses of mother-infant dyads with HLA-conferred susceptibility to type 1 diabetes (n = 22), weaned to either an extensively hydrolyzed or regular cow's milk formula, were made. The LC-MS/MS analyses included samples from the beginning of third trimester, the time of delivery, 3 months postpartum, cord blood, and samples from the infants at 3, 6, 9, and 12 months. Correlations between ranked protein intensities were detected within the dyads, together with perinatal and age-related changes. Comparison with intestinal permeability data revealed a number of significant correlations, which could merit further consideration in this context.

Assessing Immune Factors in Maternal Milk and Paired Infant Plasma Antibody Binding to Human Rhinoviruses

Before they can produce their own antibodies, newborns are protected from infections by transplacental transfer of maternal IgG antibodies and after birth through breast milk IgA antibodies. Rhinovirus (RV) infections are extremely common in early childhood, and while RV infections often result in only mild upper respiratory illnesses, they can also cause severe lower respiratory illnesses such as bronchiolitis and pneumonia. We used high-density peptide arrays to profile infant and maternal antibody reactivity to capsid and full proteome sequences of three human RVs - A16, B52, and C11. Numerous plasma IgG and breast milk IgA RV epitopes were identified that localized to regions of the RV capsid surface and interior, and also to several non-structural proteins. While most epitopes were bound by both IgG and IgA, there were several instances where isotype-specific and RV-specific binding were observed. We also profiled 62 unique RV-C dominant protein loop sequences characteristic of this species' capsid VP1 protein. Many of these RV-C sites were highly bound by IgG from one-year-old infants, indicating recent or ongoing active infections, or alternatively, a level of cross-reactivity among homologous RV-C sites.

Lactoferrin in breast milk-based powders

This study aimed to determine lactoferrin (LF) in breast milk-based powders and formulas. Lactoferrin is an important whey protein in all mammalian milks and is responsible in large part for the known antimicrobial effects of human milk in particular. As breast feeding is not always possible, formulas based on cows milk have been developed in order to meet the nutritional needs of the newborn, while more recently human breast milk-based powders have been introduced to offer the biological functionality of human milk to pre-term and critically ill babies. In the present work, the amount of LF in commercial breast milk-based powders was tested by a validated RF-HPLC method for the determination of LF in breast milk in order to examine both the applicability of the method but at a second level the amount of LF in these commercial products. The detection of LF was possible but the complexity of the matrix lead us to the use the standard addition methodology in order to achieve quantification. The results indicated that breast milk-based powders had higher amount of LF than cows milk-based formulas, both non-fortified and fortified.

Breastmilk from COVID-19 negative lactating mothers shows neutralizing activity against SARS-COV-2

Breastmilk protects newborns from infections through specific and nonspecific compounds. This study investigated the neutralizing activity against SARS-CoV-2 of breastmilk from SARS-CoV-2 negative, unvaccinated mothers, and compared it to that from infected nursing mothers. We enrolled women after COVID-19 swab testing results upon maternity admission, and divided them into two groups: group A, COVID-19-positive mothers, and group B, negative mothers. Breastmilk was randomly sampled at 2, 7, and 20 days postpartum. We collected 19 samples for Group A and 41 for Group B. A microneutralization assay was used to determine the 50% neutralization (NT50) titre. The presence of neutralizing antibodies was also determined. Group A had 100% neutralizing samples at 2 days postpartum (T0), declining 7 days postpartum (T1) and 20 days postpartum (T2). Group B samples exhibited neutralizing activity mostly at 7 days postpartum (T1) (90%). Negative mothers' samples showed no correlation between NT50 titres and antibodies' presence, suggesting that non-specific breastmilk components may exert antiviral action against SARS-CoV-2.

Breastfeeding vs. breast milk transmission during COVID-19 pandemic, which is more important?

The catastrophic coronavirus disease 2019 (COVID-19) pandemic has raised many health questions, and whether breast milk from SARS-CoV-2 infected mothers may be a vector for SARS-CoV-2 transmission has become a hot topic of concern worldwide. Currently, there are extremely limited and conflicting data on the risk of infection in infants through breastfeeding. For this reason, we investigated almost all current clinical studies and systematically analyzed the presence of SARS-CoV-2 and antibodies in the breast milk of mothers infected with SARS-CoV-2, their effects on newborns, and the mechanisms involved. A total of 82 studies were included in this review, of which 66 examined the presence of SARS-CoV-2 in breast milk samples from mothers diagnosed with COVID-19, 29 reported results of antibody detection of SARS-CoV-2 in breast milk, and 13 reported both nucleic acid and antibody test results. Seventeen studies indicated the presence of detectable SARS-CoV-2 nucleic acid in breast milk samples, and only two studies monitored viral activity, both of which reported that infectious viruses could not be cultured from RNA-positive breast milk samples. All 29 studies indicated the presence of at least one of the three antibodies, IgA, IgG and IgM, in breast milk. Five studies indicated the presence of at least one antibody in the serum of breastfed newborns. No COVID-19-related deaths were reported in all 1,346 newborns. Our study suggests that direct breastfeeding does not pose an additional risk of infection to newborns and that breast milk is a beneficial source of anti-SARS-CoV-2 antibodies that provide passive immune protection to infants. In addition, direct breastfeeding would provide maternal benefits. Our review supports the recommendation to encourage direct breastfeeding under appropriate infection control guidelines. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#myprospero, identifier: 458043.

Colostrum avoidance practice and associated factors among mothers of infants less than six months in Chencha District: cross-sectional study

BACKGROUND

Colostrum avoidance is failure to feed first breast milk to a newborn baby for the first 2 to 3 days after delivery. The problem of avoiding colostrum is prevalent in Ethiopia. But it is not adequately addressed yet. Therefore, the purpose of this study was to assess prevalence of colostrum avoidance practices and associated factors among mothers of infants aged less than six months; and to explore barriers for colostrum feeding in ChenchaZuria District.

METHODS

A community-based cross-sectional study supplemented with a qualitative study was conducted in August 2020. The quantitative data were collected from 674 mothers selected by systematic sampling using a structured questionnaire. Both bi-variable and multi-variable binary logistic regression analysis was used to identify factors associated with the colostrum avoidance practices. The statistical significance was declared at a p-value < 0.05. The qualitative data were collected using in-depth interviews from breastfeeding mothers and thematic analysis was done manually.

RESULT

The prevalence of the colostrum avoidance practice was 15.3% (95% CI: 11.4%- 18.2%). Late initiation of breastfeeding (AOR 4.15 95% CI 2.51-6.84), giving pre-lacteal feeding (AOR 3.16 95% CI 1.93-5.15), not using of postnatal care (PNC) service (AOR 1.79 95% CI 1.05-3.04), and having poor maternal knowledge regarding colostrum. (AOR 1.88 95% CI 1.14-3.08) were factors significantly associated with the colostrum avoidance practices. And in the qualitative part, cultural beliefs and misconceptions, community influence, and complementary feeding practices were found to be facilitators for the colostrum avoidance.

CONCLUSION

About one in seven mothers practiced colostrum avoidance. Factors that contributed to the colostrum avoidance practices were breastfeeding initiation, pre-lacteal feeding, PNC utilization, and maternal knowledge regarding colostrum. Thus, efforts to prevent colostrum avoidance practices should focus on strengthening and promoting PNC services utilization, timely initiation of breastfeeding, and improving awareness creation activities on the importance of colostrum feeding and risks of pre-lacteal feeding.

Breast milk in neonate oral care: oropharyngeal effects in extremely preterm infants

Ventilator-associated pneumonia (VAP) is a frequent nosocomial infection in neonatal intensive care units (NICU). Extremely preterm infants are at highest risk of developing VAP. Several studies indicate that oral care included in a preventive protocol effectively reduces neonatal VAP incidence. We investigated the effects of oral care with breast milk on oral immune defenses and microbiota in extremely preterm infants. Thirty infants born ≤ 30 weeks gestation hospitalized at our NICU were selected and divided into three groups: oral care with breast milk, formula, or sterile water. Effects on oral immune defenses in vivo were studied using ELISA to measure lactoferrin (LF) and secretory immunoglobulin A (sIgA) in pharyngeal aspirates before and after oral care. Different LF concentrations were tested in vitro to assess their effects on loads of selected bacterial species by culture. Effects on selected bacteria potentially responsible for VAP in vivo were studied by real-time PCR detection in pharyngeal aspirates before and after oral care. Oral care with breast milk significantly increases LF concentrations to 69.8 × 10³ ng/ml (p = 0.012) and sIgA to 36.8 × 10³ ng/ml (p = 0.017) in vivo. These LF concentrations considerably reduce loads of E. coli, S. epidermidis, S. aureus, and P. aeruginosa, in vitro. However, contrary to our expectation, no effect on colonization of bacteria most commonly responsible for VAP was found in vivo.

CONCLUSION

In extremely preterm infants, oral care with breast milk increases local immune defense markers (LF, sIgA), which combat bacterial infections. Further clinical trials should be conducted to evaluate their effects on VAP prevention in neonates.

WHAT IS KNOWN

• The population at higher risk to develop VAP are preterm infants. • Several studies indicate oral care within a preventive bundle is effective in reducing neonatal VAP incidence.

WHAT IS NEW

• In extremely premature infants, oral care with breast milk causes a significant increase in local immune defences in terms of lactoferrin (LF) and secretory immunoglobulin A (sIgA). • LF concentrations obtained after oral care with breast milk decreased loads of bacteria most commonly responsible for VAP in premature infants under experimental in-vitro.

Increased breastfeeding; an educational exchange program between India and Norway improving newborn health in a low- and middle-income hospital population

Background

The purpose of the project was to improve newborn health in neonatal care units in a low resource area with high neonatal mortality, predominantly by better nutrition and educational exchange of health care workers.

Method

A fourfold program to make human milk production and distribution feasible and desirable. 1 Education to enlighten health care workers and parents to the excellence of human milk. 2 Lactation counselling to address the various challenges of breastfeeding. 3 Improving infants´ general condition. 4 Infrastructure alterations in the hospital. A collaboration between hospitals in India and Norway.

Results

The number of infants receiving human milk increased pronouncedly. Systematic, professional lactation counselling, the establishment of a milk bank, and empowerment of nurses was perceived as the most important factors.

Conclusions

It is possible to greatly improve nutrition and the quality of newborn care in low/middle income settings by optimising human resources. Viable improvements can be obtained by long-term health partnership, by involving all hierarchal levels and applying locally developed customized methods.

Vaginal delivery is associated with lower levels of thiol groups, vitamin C and ferric reducing ability in colostrum compared with caesarean section

This study aimed to investigate the effects of delivery type (normal or caesarean) on the antioxidant and oxidative capacity of colostrum collected shortly after delivery. A total of 61 parturients were included in the study and divided into two groups: those who underwent vaginal delivery (n = 36) and those who underwent elective caesarean section (n = 25). Colostrum samples were collected by manual milking up to 48 h post parturition and analysed for thiol groups (-SH), vitamin C, ferric reducing ability (FRAP), nitrate/nitrite oxides (NO_x), and advanced oxidation protein products (AOPP). Colostrum levels of -SH (p = 0.0042), vitamin C (p = 0.0455), and FRAP (p = 0.0374) were significantly lower in the vaginal delivery group. The results suggest that vaginal delivery, compared to caesarean section, is associated with lower levels of antioxidants in colostrum and the mode of delivery plays an important role in the composition of antioxidants in maternal colostrum that help protect newborns from oxidative damage.IMPACT STATEMENTWhat is already known on this subject? Colostrum is the first biological fluid produced by the mother after delivery and is responsible for a child's growth, cognitive development and health. It is known that childbirth can cause oxidative imbalance, and its effects have already been evaluated in maternal and foetal blood, however, there are few studies evaluating the effects of childbirth on colostrum composition.What do the results of this study add? Previously, a study showed that caesarean section caused greater oxidation of colostrum compared to vaginal delivery. Thus, we sought to evaluate other markers (thiol groups, vitamin C, ferric reducing ability, nitrate/nitrite oxides, and advanced oxidation protein products), in a short period of time after delivery, in order to elucidate this still little discussed issue. Unlike the previous one, our study suggests that vaginal delivery, compared to caesarean section, is associated with lower levels of antioxidants in colostrum, which may make it difficult to protect newborns from oxidative damage.What are the implications of these findings for clinical practice and/or further research? Our study suggests that normal delivery can influence the antioxidant composition of maternal colostrum, and it is debateable for future clinical practice to improve eating habits during pregnancy and lactation, in order to strengthen the antioxidant capacity of colostrum and reduce oxidative damage to newborns.

New strategies for the prevention of respiratory syncytial virus (RSV)

Respiratory Syncytial Virus (RSV) is the main cause of lower respiratory tract infections (LRTIs) in newborns in the first two years of life. RSV disease has a traditional seasonal trend, with an onset and offset, duration and peak. Prematurity, male gender, bronchopulmonary dysplasia (BPD), critical congenital cardiovascular disorders (CCHD), neuromuscular diseases, congenital and inherited airways anatomical anomalies are the main risk factors for increased severity of this infection. RSV infection is associated with negative long-term respiratory outcomes, with excess of morbidity, resulting in reduced quality of life of the infected children and representing a burden for the healthcare costs and resources. Despite all the efforts, prevention remains, to date, the most effective strategy to reduce RSV-related morbidity. Among the current prevention strategies, strict hygiene, breastfeeding and passive immunization with the monoclonal antibody Palivizumab are the cornerstone. In the next future, it is likely that new possibilities of prevention will add, including use of more potent and longer-acting monoclonal antibodies, implementation of maternal vaccination in pregnancy, and active immunization in children. The purpose of this review is to provide an overview of the main current and future prevention strategies against RSV.

Human milk inhibits some enveloped virus infections, including SARS-CoV-2, in an intestinal model

Human milk is important for antimicrobial defense in infants and has well demonstrated antiviral activity. We evaluated the protective ability of human milk against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a human fetal intestinal cell culture model. We found that, in this model, human milk blocks SARS-CoV-2 replication, irrespective of the presence of SARS-CoV-2 spike-specific antibodies. Complete inhibition of both enveloped Middle East respiratory syndrome coronavirus and human respiratory syncytial virus infections was also observed, whereas no inhibition of non-enveloped enterovirus A71 infection was seen. Transcriptome analysis after 24 h of the intestinal monolayers treated with human milk showed large transcriptomic changes from human milk treatment, and subsequent analysis suggested that <i>ATP1A1</i> down-regulation by milk might be of importance. Inhibition of ATP1A1 blocked SARS-CoV-2 infection in our intestinal model, whereas no effect on EV-A71 infection was seen. Our data indicate that human milk has potent antiviral activity against particular (enveloped) viruses by potentially blocking the ATP1A1-mediated endocytic process.

Beneficial role of skim milk against drug-resistant Escherichia coli associated with pediatric diarrhoea

Background

Antibiotic-resistance in E. coli is a global issue affecting humans especially the pediatric population. Antibiotic-resistant E. coli is a pathogen frequently pediatric population as well as healthy adults.

Methods

This study aimed to examine the antibiotic resistance of E. coli causing pediatric diarrhea and its drug-resistant rates, its adhering abilities to cell line in vitro, and inhibition efficiency of a few selected chemical compounds. Clinical strains were isolated from both the healthy and infected pediatric population of Mizoram.

Results

Adhesion is a significant pathogenic process during bacterial infections, which has been employed for pathotyping of DEC by comparing adhesion efficiency in both normal (CHO-k1) and cancer (HeLa) cell lines. E. coli adherent pathotypes were identified by both PCR assay and in-vitro cell adhesion assays; the study also evaluated the adhesion inhibition ability of human skimmed milk, gentamicin, and cephalexin in-vitro. Of all isolates, 20.05% of adherent DEC (EPEC, DAEC, and EIEC) and 11.39 % of non-adherent DEC (STEC and ETEC) were found to be associated with pediatric diarrhoea in Mizoram. Human skimmed milk has a high potential adhesion inhibition against EAEC (50.25/90.90 μg/mL), EPEC (53.42/259.70 μg/mL), and EIEC (59.13/30.30 μg/mL) in both cell lines in comparison with gentamicin and cephalexin.

Conclusion

This study concludes that as a dietary supplement-human skimmed milk has high potential to prevent adhesion of DEC pathotypes in cells in-vitro thus in in-vivo.

Comparative Detection of Immunoglobulin Isotypes and Subclasses against Toxoplasma gondii Soluble Antigen in Serum and Colostrum Samples from Puerperal Women

Background: Toxoplasma gondii is an obligate intracellular parasite that can infect several species, including humans, and can cause severe damage to the fetus when the infection occurs during pregnancy. The environment and/or food contamination are critical to spreading the infection. Human milk is rich in nutrients and bioactive elements that provide growth and development of the immune system of the newborn. All isotypes of immunoglobulins are present in human colostrum and they are produced from systemic or local sources. Breastfeeding protects the infant against various pathogens, but there is no conclusive study to detect IgG subclasses in colostrum against T. gondii. Therefore, the aim of this study was to detect and evaluate the presence of antibody isotypes against T. gondii in paired samples of serum and colostrum. Methods: The study included 283 puerperal patients. ELISA (Enzyme-Linked Immunosorbent Assay) for detection of anti-T. gondii-specific IgM, IgA, and IgG isotypes and IgG1, IgG3, and IgG4 subclasses were conducted on paired samples of serum and colostrum. Results: It was found that 45.9%, 6.0%, and 2.1% of serum samples and 45.2%, 7.1%, and 2.1% of colostrum samples were positive for IgG, IgM, and IgA, respectively. Specific IgG1, IgG3, and IgG4 were positive, respectively, in 98.5%, 54.6%, and 44.6% of serum samples, in contrast with 56.9%, 78.5%, and 34.6% of colostrum samples. Thus, the predominant reactivity of IgG subclasses against T. gondii was IgG1 in serum and IgG3 in colostrum. The higher percentage of positive samples and higher levels of anti-T. gondii IgG3 antibodies were observed in colostrum, when compared to serum samples, suggesting a local production of this subclass. IgG3 and IgG1 subclasses presented different percentages of positivity in serum and colostrum. Only the IgG1 subclass showed a significant correlation between the levels of anti-T. gondii in serum and colostrum, suggesting that IgG1 in breast milk comes from a systemic source. IgG4 showed a similar percentage of positivity in both sample types, but no significant correlation was observed between their levels. Conclusion: Colostrum presents representative levels of IgM, IgA, IgG1, IgG3, and IgG4 antibodies specific to T. gondii. The detection of these antibodies presents the potential for diagnostic application of colostrum samples to better identify the diagnostic status of T. gondii infection, especially during the acute phase. In addition, breastfeeding can also be a possible source of protective antibodies for the newborn against toxoplasmosis, an anthropozoonosis maintained by environmental infection, which interferes in the public health of many countries.

Factors Influencing Early Initiation of Breastfeeding in Healthy Term Newborns: A Cross-Sectional Study at a Tertiary Care Center in South India

Background: Despite well-known benefits, rates of exclusive breastfeeding and early initiation of breastfeeding are very low. This study was conducted to identify most important and easily modifiable barriers to Early Initiation of Breast Feeding (EIBF).Methods: This hospital-based cross-sectional study was conducted from January 2018 to December 2018. Data on factors which could impact EIBF was collected by interviewing with mothers using semi-structured questionnaire.Results: Only 306 (33.7 percent) of the total 908 mother-neonate dyads enrolled received breastfeeding within 1 hour of birth. Factors affecting EIBF included: delivery by lower segment cesarean section (LSCS), lack of prenatal advice on breastfeeding, use of prelacteal feeds, and maternal illness.Conclusion: Rates of EIBF were very low in present setting. Counseling during antenatal visits on the importance of EIBF, and having adequate staff to support initiation of BF, may improve the EIBF.

Anti-RBD IgA and IgG Response and Transmission in Breast Milk of Anti-SARS-CoV-2 Vaccinated Mothers

The appearance of the severe acute respiratory syndrome virus-2 (SARS-CoV-2) has had a significant impact on the balance of public health and social life. The data available so far show that newborns and young children do not develop severe forms of COVID-19, but a small proportion of them will still need hospitalization. Even though young children represent an important vector of the infection, vaccination at such a young age was not yet considered. Thus, the question of whether potentially protective antibodies against SARS-CoV-2 could be provided to them via breast milk or across the placenta, as “passive immunity”, still stands. Materials and Methods: Between January–July 2021, we have conducted a prospective study that aimed to measure the immunoglobulin (Ig) A and IgG anti-SARS-CoV-2 titers in the breast milk of 28 vaccinated lactating mothers, sampled at 30 and 60 days after the second dose of the anti-SARS-CoV-2 Pfizer or Moderna mRNA vaccines. Anti-RBD reactive IgA and IgG antibodies were detected and quantified by a sandwich enzyme-linked immunosorbent assay. Results: Anti-RBD IgA and IgG were present in all breast milk samples, both in the first and in the second specimens, without a significant difference between those two. The anti-RBD IgA titers were approximately five-times higher than the anti-RBD IgG ones. The anti-RBD IgA and IgG titers were correlated with the infants’ age, but they were not correlated with the vaccine type or mother’s age. The anti-RBD IgA excreted in milk were inversely correlated with the parity number. Conclusions: Anti-SARS-CoV-2 IgA and IgG can be found in the milk secretion of mothers vaccinated with mRNA vaccines and, presumably, these antibodies should offer protection to the newborn, considering that the antibodies’ titers did not decrease after 60 days. The antibody response is directly proportional to the breastfed child’s age, but the amount of anti-RBD IgA decreases with the baby’s rank. The antibody response did not depend on the vaccine type, or on the mother’s age.

Increased Colostral Concentration of Macrophage Migration Inhibitory Factor in Mothers with Premature Rupture of Membranes

Objective: The colostrum contains macrophage migration inhibitory factor (MIF), which plays an important role in protecting newborns from infections. As such, colostrum may be specifically important to prevent early onset neonatal sepsis among neonates born after premature rupture of membranes (PROM). However, the effect of PROM on the colostral MIF concentration has not been previously described. The aim of this study is to compare the concentration of MIF in the colostrum of mothers with and without PROM. Methods: The study group consisted of 44 women, 22 of whom had PROM. Colostrum was expressed and collected within 72 hours of birth. MIF concentration was measured using the enzyme-linked immunosorbent assay method and compared between mothers with and without PROM. Results: There were no differences between the two groups (PROM group n = 22, control group n = 22) with regard to the age of mothers, mode of delivery, neonatal gestational age, birth weight, and sex of the infants (p > 0.05). The colostral MIF concentration was significantly higher among mothers with than without PROM (p = 0.0001). There was a positive and significant correlation between the colostral MIF concentration and PROM duration (r = 0.314, p = 0.038). Conclusions: PROM was associated with a higher colostral MIF concentration, with this concentration being positively correlated with the duration of PROM. This increased concentration may be important in offering these neonates additional protection against early onset infections, which is a risk associated with PROM.

Associations of Human Milk Oligosaccharides With Otitis Media and Lower and Upper Respiratory Tract Infections up to 2 Years: The Ulm SPATZ Health Study

Background: Human milk oligosaccharides (HMOs) support and concurrently shape the neonatal immune system through various mechanisms. Thereby, they may contribute to lower incidence of infections in infants. However, there is limited evidence on the role of individual HMOs in the risk of otitis media (OM), as well as lower and upper respiratory tract infections (LRTI and URTI, respectively) in children up to 2 years.

Objective: To investigate whether individual HMO concentrations measured at 6 weeks of lactation were associated with risk of OM, LRTI or URTI up to 2 years in breastfed infants. Associations with OM, LRTI and URTI were determined for the most prominent human milk oligosaccharides including 13 neutral, partly isomeric structures (trioses up to hexaoses), two acidic trioses, and lactose.

Design: HMO measurements and physician reported data on infections were available from human milk samples collected at 6 weeks postpartum (n = 667). Associations of HMOs with infections were assessed in crude and adjusted models using modified Poisson regression.

Results: Absolute concentrations (median [min, max], in g/L) of 2′-fucosyllactose (2′-FL) tended (p = 0.04) to be lower, while lacto-N-tetraose (LNT) was higher in the milk for infants with OM in the 1st year of life (p = 0.0046). In the milk of secretor mothers, LNT was significantly higher in the milk for infants with OM (RR [95% CI]: 0.98 [0.15, 2.60]) compared to infants without OM (RR [95% CI]: 0.76 [0.14, 2.90]) at 1 year (p = 0.0019). No statistically significant milk group differences and associations were observed for OM, LRTI, and URTI (p > 0.0031).

Conclusion: Our findings suggest that neither prominent neutral individual HMOs (ranging from 2′-FL to LNDFHs) nor acidic human milk sialyllactoses or lactose are significantly associated with a reduced or increased risk of infections in infants up to 2 years of age. Further research is needed to determine whether specific HMOs could potentially reduce the incidence or alleviate the course of distinct infections in early life.

Neurotrophic Factors in Human Milk in Early Lactation and the Effect of Holder and Microwave Pasteurization on Their Concentrations

OBJECTIVES

The objective of this study was to determine the level of brain-derived neurotrophic factor (BDNF) and glial cell line-derived neurotrophic factor (GDNF) in human milk in the first 2 weeks of breast-feeding and compare the effects of Holder pasteurization (HoP, 62.5 °C, 30 minutes) and microwave pasteurization (MP) at constant temperature (62.5 °C) on the concentraion of both neurotrophic factors (NFs).

METHODS

Concentration of NFs in human milk was determined using a commercially available ELISA assay.

RESULTS

The average concentration of BDNF and GDNF in milk was 11 ± 6 ng/mL and 336 ± 238 pg/mL, respectively. There was a positive correlation between the concentrations of BDNF and GDNF in human milk and day of lactation (r = 0.441, P < 0.05 and r = 0.482, P < 0.05, respectively). In addition, there was a significant correlation between the levels of BDNF and GDNF (r = 0.366, P < 0.05). HoP and MP for 10 minutes affected both NF levels similarly, causing degradation of BDNF by about 24% and 17%, and GDNF by 47% and 45%, respectively. Use of MP for 5 minutes resulted in preservation of nearly 91% BDNF and 79% GDNF in human milk.

CONCLUSIONS

In the pasteurization processes carried out, results showed that GDNF is more susceptible to degradation under the influence of high temperature. To the authors' best knowledge, this is the first study evaluating the effects of HoP and MP at constant temperature on the concentration of NFs in human milk. It was found that the MP for 5 minutes is the optimal method.

Lactoferrin and Immunoglobulin Concentrations in Milk of Gestational Diabetic Mothers

Gestational diabetes mellitus (GDM) is associated with an increased risk of having a high-care newborn and has an impact on maternal wellbeing. This study aimed to assess the effect of GDM on the lactoferrin (LF), secretory immunoglobulin A (SIgA), immunoglobulin G (IgG), and immunoglobulin M (IgM) concentrations in early colostrum, colostrum, and transitional milk samples of hyperglycemic (n = 53) and normoglycemic (n = 49) mothers using enzyme-linked immunosorbent assay (ELISA). The concentrations of milk lactoferrin and SIgA, but not IgG and IgM, from hyperglycemic and normoglycemic mothers, showed a similar negative correlation with lactation from the first to the fifteenth day. Apart from early colostral IgG, there were no differences in concentrations of LF and immunoglobulins in milk from hyperglycemic and normoglycemic mothers. For hyperglycemia compensated by diet (GDM G1) or insulin treatment (GDM G2), slight differences were seen for LF and IgG, but not for SIgA and IgM, during an early stage of lactation only. Early colostral IgG and colostral LF of insulin-treated mothers were higher (10.01 ± 4.48 mg/L and 11.50 ± 0.58 g/L, respectively) than for diet-control diabetic mothers (7.65 ± 5.67 mg/L and 8.05 ± 1.38 g/L, respectively). GDM of mothers does not have a significant impact on immunological quality of early milk.

Anti-Infective, Anti-Inflammatory, and Immunomodulatory Properties of Breast Milk Factors for the Protection of Infants in the Pandemic From COVID-19

COVID-19 pandemic since the end of 2019 spreads worldwide, counting millions of victims. The viral invasion, systemic inflammation, and consequent organ failure are the gravest features of coronavirus disease 2019 (COVID-19), and they are associated with a high mortality rate. The aim of this study is to evaluate the role of breast milk in the COVID-19 pandemic, analyzing its antiviral, anti-inflammatory, and immunoregulatory effects due to its bioactive components, so numerous and important for the protection of infants. The study tried to demonstrate that all the components of human milk are capable of performing functions on all the pathogenic events recognized and described in COVID-19 disease. Those human milk factors are well-tolerated and practically free of side effects, so breast milk should become a research topic to discover therapies even in this epidemic. In the first part, the mechanisms of protection and defense of the breast milk elements will be delineated; in the second section, it will describe the human milk effects in viral infections and it will be hypothesized how the known mechanisms could act in COVID infection.

The Antiviral Properties of Human Milk: A Multitude of Defence Tools from Mother Nature

The anti-infective properties of breast milk have been known for decades. In recent years, an increasing number of papers have described the variety of bioactive compounds that are present in breast milk with varying degrees of antiviral activity. However, to date, the totality of the properties of these compounds is not fully understood and, above all, their synergistic interaction is not yet known. The purpose of this review is to describe the current knowledge about the antiviral compounds in breast milk, both with specific and non-specific action against pathogens. Due to the current pandemic situation from SARS-CoV-2 (Severe acute respiratory syndrome Coronavirus-2), research has focused on a multitude of potential antiviral substances, taking breast milk as a biological model of reference. Future research is needed to expand the knowledge of these compounds, which will hopefully assist in the development of therapies applicable even at later ages.

Survival of recombinant monoclonal and naturally-occurring human milk immunoglobulins A and G specific to respiratory syncytial virus F protein across simulated human infant gastrointestinal digestion

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Naturally-occurring antibodies were more resistant to degradation than monoclonal antibodies.

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Monoclonal sIgA was more resistant to degradation than IgG and IgA.

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Monoclonal antibodies may need to be provided at a higher dose to compensate for digestive losses.

To help rationally design an antibody for oral administration, we examined how different isotypes (IgG, IgA and sIgA) with the same variable sequence affect antibody stability across digestion. We compared the degradation of recombinant palivizumab (IgG1), and recombinant IgA and sIgA versions of palivizumab spiked in human milk to the degradation of naturally-occurring anti-respiratory syncytial virus (RSV) sIgA/IgA and IgG in human milk from four donors across gastric and intestinal phases of an in vitro model of infant digestion via a validated RSV F protein ELISA. Palivizumab IgG and IgA formats were less stable than the sIgA version after complete simulated gastrointestinal digestion: palivizumab IgG, IgA and sIgA decreased across complete simulated gastrointestinal digestion by 55%, 48% and 28%, respectively. Naturally-occurring RSV F protein-specific IgG was stable across digestion, whereas naturally-occurring sIgA/IgA was stable in the gastric phase but decreased 33% in the intestinal phase of simulated digestion.

Anti-Zika virus and anti-Usutu virus activity of human milk and its components

The benefits of human milk are mediated by multiple nutritional, trophic, and immunological components, able to promote infant's growth, maturation of its immature gut, and to confer protection against infections. Despite these widely recognized properties, breast-feeding represents an important mother-to-child transmission route of some viral infections. Different studies show that some flaviviruses can occasionally be detected in breast milk, but their transmission to the newborn is still controversial. The aim of this study is to investigate the antiviral activity of human milk (HM) in its different stages of maturation against two emerging flaviviruses, namely Zika virus (ZIKV) and Usutu virus (USUV) and to verify whether HM-derived extracellular vesicles (EVs) and glycosaminoglycans (GAGs) contribute to the milk protective effect. Colostrum, transitional and mature milk samples were collected from 39 healthy donors. The aqueous fractions were tested in vitro with specific antiviral assays and EVs and GAGs were derived and characterized. HM showed antiviral activity against ZIKV and USUV at all the stages of lactation with no significant differences in the activity of colostrum, transitional or mature milk. Mechanism of action studies demonstrated that colostrum does not inactivate viral particles, but it hampers the binding of both flaviviruses to cells. We also demonstrated that HM-EVs and HM-GAGs contribute, at least in part, to the anti-ZIKV and anti-USUV action of HM. This study discloses the intrinsic antiviral activity of HM against ZIKV and USUV and demonstrates the contribution of two bioactive components in mediating its protective effect. Since the potential infectivity of HM during ZIKV and USUV infection is still unclear, these data support the World Health Organization recommendations about breast-feeding during ZIKV infection and could contribute to producing new guidelines for a possible USUV epidemic.

CNS Macrophages and Infant Infections

The central nervous system (CNS) harbors its own immune system composed of microglia in the parenchyma and CNS-associated macrophages (CAMs) in the perivascular space, leptomeninges, dura mater, and choroid plexus. Recent advances in understanding the CNS resident immune cells gave new insights into development, maturation and function of its immune guard. Microglia and CAMs undergo essential steps of differentiation and maturation triggered by environmental factors as well as intrinsic transcriptional programs throughout embryonic and postnatal development. These shaping steps allow the macrophages to adapt to their specific physiological function as first line of defense of the CNS and its interfaces. During infancy, the CNS might be targeted by a plethora of different pathogens which can cause severe tissue damage with potentially long reaching defects. Therefore, an efficient immune response of infant CNS macrophages is required even at these early stages to clear the infections but may also lead to detrimental consequences for the developing CNS. Here, we highlight the recent knowledge of the infant CNS immune system during embryonic and postnatal infections and the consequences for the developing CNS.

Comparative gene expression profiling of milk somatic cells of Sahiwal cattle and Murrah buffaloes

India is the world's largest milk producing country because of massive contribution made by cattle and buffaloes. In the present investigation, comprehensive comparative profiling of transcriptomic landscape of milk somatic cells of Sahiwal cattle and Murrah buffaloes was carried out. Genes with highest transcript abundance in both species were enriched for biological processes such as lactation, immune response, cellular oxidant detoxification and response to hormones. Analysis of differential expression identified 377 significantly up-regulated and 847 significantly down-regulated genes with fold change >1.5 in Murrah buffaloes as compared to Sahiwal cattle (p_adj <0.05). Marked enrichment of innate and adaptive immune response related GO terms and higher expression of genes for various host defense peptides such as lysozyme, defensin β and granzymes were evident in buffaloes. Genes related to ECM-receptor interaction, complement and coagulation cascades, cytokine-cytokine receptor interaction and keratinization pathway showed more abundant expression in cattle. Network analysis of the up-regulated genes delineated highly connected genes representing immunity and haematopoietic cell lineage (CBL, CD28, CD247, PECAM1 and ITGA4). For the down-regulated dataset, genes with highest interactions were KRT18, FGFR1, GPR183, ITGB3 and DKK3. Our results lend support to more robust immune mechanisms in buffaloes, possibly explaining lower susceptibility to mammary infections as compared to cattle.

Predictors of undernutrition and anemia among children aged 6–24 months in a low-resourced setting of Ghana: a baseline survey

Purpose

The purpose of this study was to identify the predictors of child undernutrition and anemia among children 6–24 months old in the East Mamprusi district, Northern region, Ghana.

Design/methodology/approach

This cross-sectional study recruited 153 children and their mothers. Weight, height and hemoglobin levels of the children were measured. A structured questionnaire based on the World Health Organization's indicators for assessing infant and young child feeding practices was used to collect data on parents' socioeconomic status, household characteristics, hygiene and sanitation practices, mothers' knowledge on feeding practices such as child's meal frequency and dietary diversity and child morbidity within the past two weeks. Predictors of child nutritional status were determined using multinomial logistic regression analysis.

Findings

Underweight in the children was significantly predicted by maternal knowledge on protein foods (AOR = 0.045, p = 0.008), time of initiation of complementary feeding (AOR = 0.222, p = 0.032) and maternal age (AOR = 9.455, p = 0.017). Feeding child from separate bowls (AOR = 0.239, p = 0.005), minimum meal frequency per child's age (AOR = 0.189, p = 0.007) and time of initiation of complementary feeding (AOR = 0.144, p = 0.009) were significant determinants of stunting among the children. Exclusive breast feeding (AOR = 7.975, p = 0.012) and child's past morbidity (AOR = 0.014, p = 0.001) significantly contributed to anemia among the children.

Research limitations/implications

This is a cross-sectional study and cannot establish causality. The small sample size also limits the generalizability of study findings. However, findings of the study highlight factors which could potentially influence the high rate of child undernutrition in the study setting.

Practical implications

This study identifies determinants of undernutrition in the East Mamprusi district, an underresourced area in Ghana. This information could inform the development/reformulation of locally sensitive key messages and targeted intervention strategies to curb the high levels of child undernutrition in the East Mamprusi district of Ghana.

Originality/value

This study identifies maternal care practices as key potential drivers of undernutrition in a low-resource setting known for high prevalence of child undernutrition. It suggests insight for large-scale studies on the predictors of child undernutrition in Northern Ghana and other resource-poor settings.

Examination of Carbohydrate Products in Feces Reveals Potential Biomarkers Distinguishing Exclusive and Nonexclusive Breastfeeding Practices in Infants

BACKGROUND

The stable isotope deuterium dose-to-mother (DTM) technique to estimate nonbreast milk water intake demonstrates that maternal self-report methods of infant feeding overestimate the true prevalence of exclusively breastfeeding practices.

OBJECTIVE

We aimed to determine potential monosaccharide and oligosaccharide markers that distinguish between exclusively breastfed (EBF) versus nonexclusively breastfed (non-EBF) infants utilizing LC-MS-based methods.

METHODS

Data for the analysis were collected as part of a larger, longitudinal study of 192 breastfed Indonesian infants aged 2 mo and followed up at 5 mo. Feces samples were collected from infants aged 2 mo (n = 188) and 5 mo (n = 184). EBF and non-EBF strata at each time point were determined via the DTM technique. Feces samples were analyzed to determine monosaccharide content using ultra-high-performance LC-triple quadrupole MS (UHPLC-QqQ MS). Relative abundances of fecal oligosaccharides were determined using nano-LC-Chip-quadrupole time-of-flight MS (nano-LC-Chip-Q-ToF MS).

RESULTS

At age 2 mo, monosaccharide analysis showed the abundance of fructose and mannose were significantly higher (+377% and +388%, respectively) in non-EBF compared with EBF infants (P <0.0001). Fructose and mannose also showed good discrimination with areas under the curve (AUC) of 0.86 and 0.82, respectively. Oligosaccharide analysis showed that a 6-hexose (Hex6) isomer had good discrimination (AUC = 0.80) between EBF and non-EBF groups at 5 mo.

CONCLUSION

Carbohydrate products, particularly fecal mono- and oligosaccharides, differed between EBF and non-EBF infants aged under 6 mo and can be used as potential biomarkers to distinguish EBF versus non-EBF feeding practices.

Survival of Recombinant Monoclonal Antibodies (IgG, IgA and sIgA) Versus Naturally-Occurring Antibodies (IgG and sIgA/IgA) in an Ex Vivo Infant Digestion Model

To prevent infectious diarrhea in infants, orally-supplemented enteric pathogen-specific recombinant antibodies would need to resist degradation in the gastrointestinal tract. Palivizumab, a recombinant antibody specific to respiratory syncytial virus (RSV), was used as a model to assess the digestion of neutralizing antibodies in infant digestion. The aim was to determine the remaining binding activity of RSV F protein-specific monoclonal and naturally-occurring immunoglobulins (Ig) in different isoforms (IgG, IgA, and sIgA) across an ex vivo model of infant digestion. RSV F protein-specific monoclonal immunoglobulins (IgG, IgA, and sIgA) and milk-derived naturally-occurring Ig (IgG and sIgA/IgA) were exposed to an ex vivo model of digestion using digestive samples from infants (gastric and intestinal samples). The survival of each antibody was tested via an RSV F protein-specific ELISA. Ex vivo gastric and intestinal digestion degraded palivizumab IgG, IgA, and sIgA (p < 0.05). However, the naturally-occurring RSV F protein-specific IgG and sIgA/IgA found in human milk were stable across gastric and intestinal ex vivo digestion. The structural differences between recombinant and naturally-occurring antibodies need to be closely examined to guide future design of recombinant antibodies with increased stability for use in the gastrointestinal tract.

DNA Methylation Signatures of Breastfeeding in Buccal Cells Collected in Mid-Childhood

Breastfeeding has long-term benefits for children that may be mediated via the epigenome. This pathway has been hypothesized, but the number of empirical studies in humans is small and mostly done by using peripheral blood as the DNA source. We performed an epigenome-wide association study (EWAS) in buccal cells collected around age nine (mean = 9.5) from 1006 twins recruited by the Netherlands Twin Register (NTR). An age-stratified analysis examined if effects attenuate with age (median split at 10 years; n<10 = 517, mean age = 7.9; n>10 = 489, mean age = 11.2). We performed replication analyses in two independent cohorts from the NTR (buccal cells) and the Avon Longitudinal Study of Parents and Children (ALSPAC) (peripheral blood), and we tested loci previously associated with breastfeeding in epigenetic studies. Genome-wide DNA methylation was assessed with the Illumina Infinium MethylationEPIC BeadChip (Illumina, San Diego, CA, USA) in the NTR and with the HumanMethylation450 Bead Chip in the ALSPAC. The duration of breastfeeding was dichotomized ('never' vs. 'ever'). In the total sample, no robustly associated epigenome-wide significant CpGs were identified (α = 6.34 × 10-8). In the sub-group of children younger than 10 years, four significant CpGs were associated with breastfeeding after adjusting for child and maternal characteristics. In children older than 10 years, methylation differences at these CpGs were smaller and non-significant. The findings did not replicate in the NTR sample (n = 98; mean age = 7.5 years), and no nearby sites were associated with breastfeeding in the ALSPAC study (n = 938; mean age = 7.4). Of the CpG sites previously reported in the literature, three were associated with breastfeeding in children younger than 10 years, thus showing that these CpGs are associated with breastfeeding in buccal and blood cells. Our study is the first to show that breastfeeding is associated with epigenetic variation in buccal cells in children. Further studies are needed to investigate if methylation differences at these loci are caused by breastfeeding or by other unmeasured confounders, as well as what mechanism drives changes in associations with age.

Breast Milk Prefusion F Immunoglobulin G as a Correlate of Protection Against Respiratory Syncytial Virus Acute Respiratory Illness

Background

Transplacental respiratory syncytial virus (RSV) antibody transfer has been characterized, but little is known about the protective effect of breast milk RSV-specific antibodies. Serum antibodies against the prefusion RSV fusion protein (pre-F) exhibit high neutralizing activity. We investigate protection of breast milk pre-F antibodies against RSV acute respiratory infection (ARI).

Methods

Breast milk at 1, 3, and 6 months postpartum and midnasal swabs during infant illness episodes were collected in mother-infant pairs in Nepal. One hundred seventy-four infants with and without RSV ARI were matched 1:1 by risk factors for RSV ARI. Pre-F immunoglobulin A (IgA) and immunoglobulin G (IgG) antibody levels were measured in breast milk.

Results

The median breast milk pre-F IgG antibody concentration before illness was lower in mothers of infants with RSV ARI (1.4 [interquartile range {IQR}, 1.1-1.6] log10 ng/mL) than without RSV ARI (1.5 [IQR, 1.3-1.8] log10 ng/mL) (P = .001). There was no difference in median maternal pre-F IgA antibody concentrations in cases vs controls (1.7 [IQR, 0.0-2.2] log10 ng/mL vs 1.7 [IQR, 1.2-2.2] log10 ng/mL, respectively; P = .58).

Conclusions

Low breast milk pre-F IgG antibodies before RSV ARI support a potential role for pre-F IgG as a correlate of protection against RSV ARI. Induction of breast milk pre-F IgG may be a mechanism of protection for maternal RSV vaccines.

Storage-Dependent Generation of Potent Anti-ZIKV Activity in Human Breast Milk

Zika virus (ZIKV) causes congenital neurologic birth defects, notably microcephaly, and has been associated with other serious complications in adults. The virus has been detected in human breast milk and possible transmissions via breastfeeding have been reported. Breast milk is rich in nutrients and bio-active substances that might directly affect viral infectivity. Thus, here, we analyzed the effect of human breast milk on ZIKV infection. We observed that fresh human breast milk had no effect on ZIKV, but found that upon storage, milk effectively suppressed infection. The antiviral activity is present in the fat-containing cream fraction of milk and results in the destruction of the structural integrity of viral particles, thereby abrogating infectivity. The release of the factor is time dependent but varies with donors and incubation temperatures. The viral titer of milk that was spiked with ZIKV decreased considerably upon storage at 37 °C for 8 h, was lost entirely after 2 days of 4 °C storage, but was not affected at -20 °C. This suggests that cold storage of milk inactivates ZIKV and that the antiviral factor in milk may also be generated upon breastfeeding and limit this transmission route of ZIKV.

Stakeholder Attitudes towards Donating and Utilizing Donated Human Breastmilk

The promotion and support of human milk banks (HMBs) can enhance exclusive breastfeeding rates. The success and sustainability of HMBs depend on the support from relevant healthcare workers and related communities. This study aimed to determine attitudes of key stakeholders, including mothers, healthcare workers and grandmothers, regarding the donation and receipt of human breastmilk. This study was conducted at a public hospital and clinics in the North West Province, South Africa. Eight focus group discussions explored the attitudes regarding donating and receiving human breastmilk: three groups with mothers of infants (n = 13), three with grandmothers (>60 years old) (n = 17) and two with healthcare professionals working with infants (n = 11). Four main themes emerged: perception regarding breast and formula feeding; exposure to the concept of “wet nursing”; breastmilk donation; and utilization and opinions of community members and traditional healers. Specific barriers identified included the processes for donating and receiving milk, safety, human immuno-deficiency virus (HIV) screening and cultural beliefs. Mothers’ fears included having insufficient milk for their own infants, changes in the quality of donated milk during pasteurization and transportation and HIV transmission. Despite barriers towards donations to and the use of HMBs, sufficient information could enhance donations by mothers and breastmilk utilization.

Factors associated with fatal cases of acute respiratory infection (ARI) among hospitalized patients in Guatemala

Background

Acute respiratory infection (ARI) is an important cause of mortality in children and adults. However, studies assessing risk factors for ARI-related deaths in low- and middle-income settings are limited. We describe ARI-related death and associated factors among children aged < 2 years and adults aged ≥18 years hospitalized with ARI in Guatemala.

Methods

We used respiratory illness surveillance data in Guatemala from 2007 to 2013. ARI was defined as evidence of acute infection and ≥ 1 sign/symptom of respiratory disease in hospitalized patients. Clinical, sociodemographic, and follow-up data were gathered. Nasopharyngeal/oropharyngeal swabs were collected from patients with ARI and tested for 6 respiratory viruses; urine was collected only from adults with ARI and tested for pneumococcal antigen. Blood cultures and chest radiographs were performed at the physician’s discretion. Radiographs were interpreted per World Health Organization guidelines to classify endpoint pneumonia (i.e. suggestive of bacterial pneumonia). Multivariable logistic regression was used to compare characteristics of patients with fatal cases, including those who died in-hospital or were discharged in a moribund state, with those of patients with non-fatal cases.

Results

Among 4109 ARI cases identified in hospitalized children < 2 years old, 174 (4%) were fatal. Median age at admission was 4 and 6 months for children with fatal and non-fatal cases, respectively. Factors associated with fatality included low weight-for-age, low family income, heart disease, and endpoint pneumonia; breastfeeding and respiratory syncytial virus (RSV) detection were negatively associated with fatality. Among 1517 ARI cases identified in hospitalized adults ≥18 years, 181 (12%) episodes were fatal. Median age at admission was 57 years for adults with fatal and non-fatal cases. Low body mass index, male sex, kidney disease, and endpoint pneumonia were significantly more common among patients with fatal versus non-fatal cases.

Conclusions

Our findings highlight some of the factors that must be addressed in order to reduce ARI-related mortality, including promotion of good nutrition, breastfeeding, management and prevention of chronic comorbidities, and poverty reduction. Although no specific pathogen increased risk for death, endpoint pneumonia was significantly associated with fatality, suggesting that the pneumococcal conjugate vaccine could contribute to future reductions in ARI-related mortality.

Stem cells in human breast milk

Recent studies have demonstrated that breast milk contains a population of cells displaying many of the properties typical of stem cells. This review outlines progress made in this newly emerging field of stem cell biology and provides an analysis of the available data on purification, propagation and differentiation of certain types of progenitor cells from breast milk. The possible fates of breast milk cells, including microchimerism caused by their transmission to the distant organs of the infant, are also discussed. Unique properties of breast milk-derived stem cells, such as their unusually low tumorigenic potential and their negligible ability to form teratomas, are highlighted as obvious advantages for using these cells in regenerative therapy.

A new dilution-enrichment sample preparation strategy for expanded metabolome monitoring of human breast milk that overcomes the simultaneous presence of low- and high-abundance lipid species

The complex nature of human breast milk (HBM) makes samples difficult to analyze, requiring several extraction techniques and analytical platforms to obtain high metabolome coverage. In this work, we combined liquid-liquid extraction (LLE) and solid-phase extraction (SPE) techniques to prepare HBM samples to overcome the challenge of low- and high-abundance lipid species, enabling the semiquantitative analysis of total HBM lipids in one liquid chromatography-mass spectrometry (LC-MS) run. A nonorganic fraction obtained during the LLE step was used to analyze small polar metabolites. This analytical approach allows extensive metabolome coverage, especially for low-abundance glycerophospholipids and sphingolipids. The method was applied to monitor short-term metabolome changes in HBM composition within individual mothers and the results showed variable metabolite composition patterns. Simultaneous detection of high-abundance glycerolipids and low-abundance but not less significant phospholipids in one LC-MS run saves time, decreases cost, and enables comprehensive insight into the dynamics of HBM composition.

Enhancement of immune response mediated by oropharyngeal colostrum administration in preterm neonates

BACKGROUND

The immune system of preterm infants is immature, being a significant cause of morbidity and mortality, particularly in the preterm infant. Oropharyngeal colostrum administration could be an immunomodulatory aid. Our aim was to evaluate the effect of oropharyngeal colostrum on the serum levels of immunoglobulins, lactoferrin, and resistin during the first month of life and to track the clinical outcome of the neonates.

METHODS

One hundred preterm neonates born at <32 weeks of gestation and/or weighing < 1500 g and assisted in the Neonatal Intensive Care Unit were enrolled and divided into two groups: colostrum (n = 48) and control (n = 52). The subjects assigned to the colostrum group received 0.2 mL of colostrum (oropharyngeal route) every 4 hours for the first 15 days of life, and if mothers have inability to breastfeed, they were included in the control group (no oropharyngeal colostrum). Serum concentrations of IgA, IgM, and IgG1, lactoferrin, and resistin were assessed in both groups at 1, 3, 15, and 30 days of life. Clinical data during hospitalization were collected.

RESULTS

IgA and IgM increased in preterm neonates who were administered colostrum for 15 and 30 days. Lactoferrin increased after 30 days, and resistin increased after 15 days of supplying oropharyngeal colostrum. The colostrum group underwent full enteral nutrition before, and no differences were observed in the common neonatal morbidities.

CONCLUSION

Oropharyngeal colostrum administration is safe in preterm neonates and improves their immunologic profile, showing a potential role as an immunomodulatory agent.

Colostrum immunoglobulins and oxidative capacity may be affected by infant sex and maternal age and parity

Background/aim

The aims of this study were to determine the levels of the total antioxidant status (TAS), the total oxidant status (TOS), the oxidative stress index (OSI), and the concentration of immunoglobulin A (IgA) and M (IgM) in colostrum, and evaluate relationships between these parameters and maternal age, maternal parity, and infant sex.

Materials and methods

The analysis was performed in serum samples of colostrum which were collected from 90 mothers on the first day of lactation between 10:00 and 12:00 AM.

Results

The measurements established that no significant association existed between the TAS level of colostrum and parity, maternal age, or infant sex. However, mothers 18 to 30 years of age had significantly lower colostrum TOS and OSI levels compared with mothers older than 30 years of age. IgA and IgM values of the colostrum of primiparous mothers were significantly higher than those of multiparous mothers, whereas no correlations existed with the age of the mother. Additionally, significantly higher colostrum IgA and IgM values were observed in female infants fed colostrum compared with male infants.

Conclusion

In conclusion, sex-based hormonal changes in mothers during pregnancy may be associated with the different colostral immunoglobulin levels for male and female infants.

Influence of infant feeding on the excretion of gluten immunopeptides in feces

INTRODUCTION

the secretion of antigens from the diet into breast milk has been extensively documented. The transfer of gliadin could be critical for the development of an immune response.

OBJECTIVES

to investigate the presence of immunogenic gluten peptides in the feces of infants fed with different diets.

MATERIAL AND METHODS

a blind, prospective, controlled, collaborative study was performed in three hospitals, between September 2016 and January 2017. The study protocol was approved by the Ethics Committee of the hospitals in Seville prior to starting the study.

RESULTS

the cohort was divided into three groups of 30 infants: an experimental group (average age 9.2 ± 2.8 weeks) with exclusive breastfeeding, a control group 1 (average age 10.3 ± 3.3 weeks) exclusively fed with onset formula and a control group 2 (average age 56 ± 3.7 weeks) with infants that consumed gluten on a regular basis. The peptide 33-mer of gliadin was negative in all feces samples from both the experimental and control group 1. With regard to control group 2, the peptide 33-mer of gliadin was negative in 23% of cases (seven children). There was no difference in the amount of gluten ingested by these children compared to those who excreted the 33-mer peptide.

CONCLUSIONS

the failure to detect gluten in the feces of infants that were exclusively breastfed indicates that it is probably below the limits of detection. Healthy children who consume gluten may not excrete it in feces.

Chemistry of Human Breast Milk-A Comprehensive Review of the Composition and Role of Milk Metabolites in Child Development

Early nutrition has an enormous influence on a child's physiological function, immune system maturation, and cognitive development. Human breast milk (HBM) is recognized as the gold standard for human infant nutrition. According to a WHO report, breastfeeding is considered as an unequaled way of providing ideal food to the infant, which is required for his healthy growth and development. HBM contains various macronutrients (carbohydrates, proteins, lipids, and vitamins) as well as numerous bioactive compounds and interactive elements (growth factors, hormones, cytokines, chemokines, and antimicrobial compounds. The aim of this review is to summarize and discuss the current knowledge about metabolites, which are the least understood components of HBM, and their potential role in infant development. We focus on small metabolites (<1500 Da) and characterize the chemical structure and biological function of polar metabolites such as human milk oligosaccharides, nonprotein molecules containing nitrogen (creatine, amino acids, nucleotides, polyamines), and nonpolar lipids. We believe that this manuscript will provide a comprehensive insight into a HBM metabolite composition, chemical structure, and their role in a child's early life nutrition.

Using donor human milk to feed vulnerable term infants: a case series in KwaZulu Natal, South Africa

BACKGROUND

Donor human milk is the World Health Organization's recommendation for infant feeding when the mother's own breast milk is unavailable. Breast milk has been shown to reduce morbidity and mortality and in low birthweight infants, donor milk reduces the incidence of necrotising enterocolitis, late onset sepsis and improves outcomes. There is a paucity of literature documenting outcomes of using donor human milk in older children who need additional support for a variety of health issues.

CASE PRESENTATION

A series of seven case studies is presented of orphaned and abandoned children, many of whom were either HIV exposed or positive. All children were fed with pasteurised donor human milk at a transition home and their progress reported.

CONCLUSIONS

Although detailed medical records were not always available, the case studies provide anecdotal evidence of the protective effects of donor human milk against failure to thrive, diarrhoea, atopic dermatitis, and opportunistic infections.

Oropharyngeal colostrum in preventing mortality and morbidity in preterm infants

BACKGROUND

Placing a small volume of colostrum directly onto the buccal mucosa of preterm infants during the early neonatal period may provide immunological and growth factors that stimulate the immune system and enhance intestinal growth. These benefits could potentially reduce the risk of infection and necrotising enterocolitis (NEC) and improve survival and long-term outcome.

OBJECTIVES

To determine if early (within the first 48 hours of life) oropharyngeal administration of mother's own fresh or frozen/thawed colostrum can reduce rates of NEC, late-onset invasive infection, and/or mortality in preterm infants compared with controls. To assess trials for evidence of safety and harm (e.g. aspiration pneumonia). To compare effects of early oropharyngeal colostrum (OPC) versus no OPC, placebo, late OPC, and nasogastric colostrum.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 8), MEDLINE via PubMed (1966 to August 2017), Embase (1980 to August 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to August 2017). We also searched clinical trials registries for ongoing and recently completed trials (clinicaltrials.gov; the World Health Organization International Trials Registry (www.whoint/ictrp/search/en/), and the ISRCTN Registry), conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We performed the last search in August 2017. We contacted trial investigators regarding unpublished studies and data.

SELECTION CRITERIA

We searched for published and unpublished randomised controlled trials comparing early administration of oropharyngeal colostrum (OPC) versus sham administration of water, oral formula, or donor breast milk, or versus no intervention. We also searched for studies comparing early OPC versus early nasogastric or nasojejunal administration of colostrum. We considered only trials that included preterm infants at < 37 weeks' gestation. We did not limit the review to any particular region or language.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened retrieved articles for inclusion and independently conducted data extraction, data analysis, and assessments of 'Risk of bias' and quality of evidence. We graded evidence quality using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We contacted study authors for additional information or clarification when necessary.

MAIN RESULTS

We included six studies that compared early oropharyngeal colostrum versus water, saline, placebo, or donor, or versus no intervention, enrolling 335 preterm infants with gestational ages ranging from 25 to 32 weeks' gestation and birth weights of 410 to 2500 grams. Researchers found no significant differences between OPC and control for primary outcomes - incidence of NEC (typical risk ratio (RR) 1.42, 95% confidence interval (CI) 0.50 to 4.02; six studies, 335 infants; P = 0.51; I² = 0%; very low-quality evidence), incidence of late-onset infection (typical RR 0.86, 95% CI 0.56 to 1.33; six studies, 335 infants; P = 0.50; I² = 0%; very low-quality evidence), and death before hospital discharge (typical RR 0.76, 95% CI 0.34 to 1.71; six studies, 335 infants; P = 0.51; I² = 0%; very low-quality evidence). Similarly, meta-analysis showed no difference in length of hospital stay between OPC and control groups (mean difference (MD) 0.81, 95% CI -5.87 to 7.5; four studies, 293 infants; P = 0.65; I² = 49%). Days to full enteral feeds were reduced in the OPC group with MD of -2.58 days (95% CI -4.01 to -1.14; six studies, 335 infants; P = 0.0004; I² = 28%; very low-quality evidence).The effect of OPC was uncertain because of small sample sizes and imprecision in study results (very low-quality evidence).No adverse effects were associated with OPC; however, data on adverse effects were insufficient, and no numerical data were available from the included studies.Overall the quality of included studies was low to very low across all outcomes. We downgraded GRADE outcomes because of concerns about allocation concealment and blinding, reporting bias, small sample sizes with few events, and wide confidence intervals.

AUTHORS' CONCLUSIONS

Large, well-designed trials would be required to evaluate more precisely and reliably the effects of oropharyngeal colostrum on important outcomes for preterm infants.

Expression of Granulisyn, Perforin and Granzymes in Human Milk over Lactation and in the Case of Maternal Infection

Human milk has been previously found to contain various types of leukocytes however specific characteristics of these cells, such as whether they contain cytolytic antimicrobial proteins that may induce pathogen directed cell death, are unknown. This project aims to examine the presence and localization of immune proteins such as perforin, granulysin and granzymes in human milk cells at the protein and mRNA level. Genes encoding these proteins were confirmed in human milk cell samples, which were particularly enriched in early milk and in the case of maternal infection. Fluorescence activated cell sorting (FACS) was used to investigate the co-expression of these proteins with pan-immune cell marker CD45 and epithelial marker EPCAM. Co-expression of antimicrobial proteins was found predominantly in CD45 positive cells, also increasing in the case of maternal infection. Our study suggests that human milk contains cells that carry hallmarks of activated or memory T-cells which are enriched early in lactation and in the case of maternal infection. Presence and prevalence of these cells in human milk may indicate a role in the protection of the maternal breast or for delivery to the vulnerable infant.

Nutrient enrichment of human milk with human and bovine milk-based fortifiers for infants born weighing <1250 g: a randomized clinical trial

Background

Human milk-based fortifiers (HMBFs) are being adopted in neonatal care to enrich the nutrients in human milk for very low birth weight (VLBW) infants despite being costly and there being limited efficacy data. No randomized clinical trial has evaluated the use of HMBF compared with bovine milk-based fortifiers (BMBFs) in the absence of formula feeding.

Objective

To determine if HMBF compared with BMBF for routine nutrient enrichment of human milk improves feeding tolerance, reduces morbidity, reduces fecal calprotectin (a measure of gut inflammation), and supports the growth of infants <1250 g.

Design

In this blinded randomized clinical trial, infants born weighing <1250 g were recruited from neonatal units in Ontario, Canada between August 2014 and November 2015. The infants were fed mother's milk and donor milk as required. Fortification commenced at 100 mL/kg per day of HMBF (0.81 kcal/mL) or BMBF (0.72 kcal/mL) and advanced at 140 mL/kg per day to 0.88 and 0.78 kcal/mL, respectively. The primary outcome was percentage of infants with a feeding interruption for ≥12 h or a >50% reduction in feeding volume. Secondary outcomes included a dichotomous mortality and morbidity index (i.e., affirmative for any one of death, late-onset sepsis, necrotizing enterocolitis, chronic lung disease, or severe retinopathy of prematurity), fecal calprotectin, and growth.

Results

Of 232 eligible infants, 127 (54.7%) were randomized (n = 64 HMBF, n = 63 BMBF). Mean ± SD birth weight and gestational age of infants were 888 ± 201 g and 27.7 ± 2.5 wk, respectively. No statistically significant differences were identified in feeding interruptions [17/64 HMBF, 20/61 BMBF; unadjusted risk difference: -6.2% (95% CI: -22.2%, 9.8%)]. There was no statistically significant difference in the mortality and morbidity index (48.4% HMBF, 49.2% BMBF, adjusted P = 0.76), changes in fecal calprotectin, or growth z scores.

Conclusions

Among infants born weighing <1250 g and exclusively fed human milk, the use of HMBF did not improve feeding tolerance or reduce mortality and morbidity compared with BMBF. This trial was registered at clinicaltrials.gov as NCT02137473.

Supporting Mothers of Very Preterm Infants and Breast Milk Production: A Review of the Role of Galactogogues

Human milk, either mother’s own milk or donor human milk, is recommended as the primary source of nutrition for very preterm infants. Initiatives should be in place in neonatal units to provide support to the mother as she strives to initiate and maintain a supply of breast milk for her infant. The use of galactogogues are considered when these initiatives alone may not be successful in supporting mothers in this endeavor. Although there are non-pharmacologic compounds, this review will focus on the pharmacologic galactogogues currently available and the literature related to their use in mothers of very preterm infants.

Predictors of death in infants with probable serious bacterial infection

BackgroundBacterial infections account for a significant proportion of neonatal and infant mortality globally. We aimed to identify predictors of death in infants with probable serious bacterial infection (PSBI) defined as signs/symptoms of possible serious bacterial infection along with baseline C-reactive protein (CRP) ≥12 mg/l.MethodsWe did a secondary analysis using the data collected from 700 infants with PSBI who participated in a randomized controlled trial in India in which zinc or placebo was given in addition to the standard antibiotics. Logistic regression was used to estimate the associations between relevant variables and death within 21 days.ResultsThose infants who were fed cow's milk or formula before the illness episode had 3.7-fold (95% confidence interval (CI) 1.5-9.3) and 5.3-fold (95% CI 2.0-13.6) higher odds of death, respectively. Lethargy (odds ratio (OR) 2.4, 95% CI 1.1-5.4) and CRP (OR 1.9, 95% CI 1.1-3.3) were also independent predictors of death. In the model including only clinical features, female gender (OR 2.25, 95% CI 1.0-5.0), abdominal distention (3.7, 95% CI 1.1-12.3), and bulging fontanelle (5.8, 95% CI 1.1-30.5) were also independent predictors for death.ConclusionFormula or cow milk feeding prior to the illness, lethargy at the time of presentation, and high serum CRP levels predicted death in infants with PSBI.

Importance of maternal diet in the training of the infant's immune system during gestation and lactation

Latest forecasts predict that half of the European population will be allergic within the coming 15 years, with food allergies contributing substantially to the total burden; preventive measures are urgently needed. Unfortunately, all attempted alimentary strategies for primary prevention of allergic diseases through allergen avoidance so far have failed. This also holds true for the prevention of food allergies in breastfed infants by the common practice of excluding certain foods with allergenic potential from the maternal diet. As a preventive measure, therefore, exclusion diets should be discouraged. They can exhaust nursing mothers and negatively impact both their nutritional status as well as their motivation to breastfeed. A prolonged exclusion diet may be indicated solely in cases of doctor-diagnosed food allergy following rigid medical tests (e.g. double-blind placebo-controlled food challenges). Indicated cases usually involve exclusion of only a few food items. Continued breastfeeding is generally important for many aspects of the infant's health, including the training of the infant's immune responses to foreign compounds and avoidance of overshooting inflammatory responses. Recent studies suggest that the presence of maternal dietary proteins in amniotic fluid, cord blood, and human milk might support the induction of tolerance towards solid foods in infants. These are exactly the same species of proteins or remnants thereof that, in comparatively few cases, trigger allergic responses. However, the insight that the proteins of maternal dietary origin in human milk are more likely to be cure (or, more precise, directing prevention) than curse has still largely evaded the attention of health care professionals consulted by worried breastfeeding mothers. In this paper, we summarize recent literature on the importance of exposure to dietary proteins in the establishment of immunological tolerance and hence prevention of allergic disease. Multiple organizations have used the scientific knowledge to build (local) guidelines (e.g. AAAAI, EAACI, BSACI) that can support health care professionals to provide the best strategy to prevent the onset of allergic diseases. We thus hope to clarify existing confusion about the allergenic propensities of dietary proteins during early life, which has contributed to exaggerated fears around the diet of pregnant and breastfeeding mothers.

The controversial role of breast milk in GBS late-onset disease

Group B streptococcus (GBS) is one of the most common causes of neonatal sepsis and meningitis. Intra-partum antibiotic prophylaxis does not play a significant role in reducing the risk of GBS late-onset disease. One of the proposed mechanisms for GBS late-onset disease is infection through contaminated breast milk. Infants in whom breast milk is thought to be the source for GBS late-onset disease are more heavily colonised and reports suggest they have a higher recurrence rate compared to infants with other potential sources. There is no consensus whether the breast milk of mothers of infants with GBS late-onset disease, especially those with recurrent episodes, should be tested for GBS. In addition, recommendations differ on whether breast-feeding should be interrupted or breast milk pasteurised, or whether the mother and infant should be treated for colonisation. In this review we discuss these different approaches.