Preparation of Powdered Infant Formula: Could Product's Safety Be Improved?

Clinically Relevant Topics and New Tendencies in Childhood Nutrition during the First 2 Years of Life: A Survey among Primary Care Spanish Paediatricians

A multicenter cross-sectional study was conducted among 245 experienced Spanish paediatricians, who completed an online survey based on clinically relevant topics in nutrition during the first two years of life and their recommendations to parents in daily clinical practice. Most participants advise about the choking risk associated with baby-led weaning (BLW) and more than 60% consider that infants can receive an insufficient variety and quantity of nutrients with this practice. The general opinion is that there is a lack of evidence for delaying the introduction of gluten and other allergenic foods in the complementary feeding of healthy infants. Most participants agree/strongly agree that two servings of dairy products are the adequate daily amount in a diversified diet and 93.4% disagree/strongly disagree with the use of vegetal beverages under 1 year of life. There is a general agreement to avoid added salt and sugar before 12 months of life, the consideration that organic foods do not have a better nutritional profile than non-organic ones, and the limitations of vegetarian diets especially for adequate provision of micronutrients. Overall, there is an adequate knowledge of the new trends by paediatricians and younger ones seemed more in favor of them and interested in receiving more information on most topics.

Inactivation of Cronobacter sakazakii in powdered infant formula with probiotics and metagenomic analysis

In the present study, proper manual for powdered infant formula with probiotics (PIF-P) to prevent the contamination of Cronobacter sakazakii was investigated. First, the population of C. sakazakii and LAB in three different PIF-P samples were quantitatively analyzed after reconstituted with hydrothermal treatments. When C. sakazakii was inoculated into reconstituted infant formula with probiotics (RIF-P), it was immediately reduced below the detection limit by 60-65 °C hydrothermal treatment whereas reduction levels of LAB was 1-2 log CFU/g. When heat resistance of C. sakazakii inoculated to PIF-P with 4 h drying was compared with that inoculated to RIF-P samples, the heat resistance of C. sakazakii increased significantly after the inoculation in PIF-P with drying. Metagenomic analysis revealed that Lactobacillus and Bifidobacterium were dominant genus in all three groups and there was no significant difference in the microbial community of untreated PIF sample and hydrothermal treated samples.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10068-023-01503-x.

Effect of exclusive breastfeeding and other infant and young child feeding practices on childhood morbidity outcomes: associations for infants 0-6 months in 5 South Asian countries using Demographic and Health Survey data

BACKGROUND

Despite growing evidence of the impacts of exclusively breastfeeding infants during the first 6 months of life on preventing childhood infections and ensuring optimal health, only a small number of studies have quantified this association in South Asia.

METHODS

We analyzed data from the Demographic and Health Surveys in Afghanistan (2015; n = 3462), Bangladesh (2017-2018; n = 1084), India (2019-2021; n = 26,101), Nepal (2022; n = 581), and Pakistan (2017-2018; n = 1,306), including babies aged 0-6 months. Multivariate logistic regression models were used to determine the association between exclusive breastfeeding in the last 24 h and diarrhoea, acute respiratory infections, and fever in the two weeks before the survey. We also examined the association between other infant and young feeding indicators and these outcomes.

RESULTS

Infants who were exclusive breastfed had decreased odds of diarrhoea in Afghanistan (AOR: 0.49, 95% CI 0.35, 0.70), India (AOR: 0.80, 95% CI 0.70, 0.91), and Nepal (AOR: 0.42, 95% CI 0.20, 0.89). Compared with infants who were not exclusive breastfed, infants who were exclusively breastfed were less likely to have fever in Afghanistan (AOR: 0.36, 95% CI 0.26, 0.50) and India (AOR: 0.75, 95% CI 0.67, 0.84). Exclusive breastfeeding was associated with lower odds of acute respiratory infections in Afghanistan (AOR: 0.57, 95% CI 0.39, 0.83). Early initiation of breastfeeding was protective against diarrhoea in India. Bottle feeding was a risk factor for diarrhoea in India and for fever in Afghanistan and India. Bottle feeding was also a risk factor for acute respiratory infection in Afghanistan and India.

CONCLUSIONS

Not exclusive breastfeeding is a risk factor for diarrhoea, acute respiratory infections, and fever in some South Asian countries. These findings could have substantial implications for global and national efforts to increase exclusive breastfeeding rates. More support, advocacy, and action are required to boost breastfeeding rates as a crucial public health measure.

The safety of at home powdered infant formula preparation: A community science project

Formula fed infants experience gastrointestinal infections at higher rates than breastfed infants, due in part to bacteria in powdered infant formula (PIF) and bacterial contamination of infant feeding equipment. The United Kingdom National Health Service (UK NHS) has adopted the World Health Organization recommendation that water used to reconstitute PIF is ≥70°C to eliminate bacteria. We used community science methods to co-design an at home experiment and online questionnaire ('research diary') to explore the safety of PIF preparation compared to UK NHS guidelines. 200 UK-based parents of infants aged ≤12 months were recruited; 151 provided data on PIF preparation, and 143 were included in the analysis of water temperatures used to reconstitute PIF. Only 14.9% (n = 11) of 74 PIF preparation machines produced a water temperature of ≥70°C compared with 78.3% (n = 54) of 69 kettle users (p < 0.001). The mean temperature of water dispensed by PIF preparation machines was 9°C lower than kettles (Machine M = 65.78°C, Kettle M = 75.29°C). Many parents did not always fully follow NHS safer PIF preparation guidance, and parents did not appear to understand the potential risks of PIF bacterial contamination. Parents should be advised that the water dispensed by PIF preparation machines may be below 70°C, and could result in bacteria remaining in infant formula, potentially leading to gastrointestinal infections. PIF labelling should advise that water used to prepare PIF should be ≥70°C and highight the risks of not using sufficiently hot water, per WHO Europe advice. There is an urgent need for stronger consumer protections regarding PIF preparation devices.

Estimated daily intake and health risk assessment of toxic elements in infant formulas

In this study, the heavy metal (Al, Mn, Co, Cu, Zn, As, Se, Cd, Sn, Pb and Hg) concentrations were determined in a total of seventy-two infant formula samples manufactured by sixteen different brands in Türkiye. During the analyses, inductively coupled plasma MS was used in evaluating the nutritional profile and the toxicological risk associated with the consumption of these products. Given the analysis results, the highest Pb content was found in milk-based 'beginner' formulas (0-6 months, three samples) packed in metal containers. The highest concentration of Mn was found in powdered infant formula (Brand 3) that is suitable for 9-12-month-olds. Mn level was found to be above the limit values in nine samples (12·5 %). Cd level exceeded the limit values in two infant formula samples of Brand 3 (0·038 µg/g) and Brand 15 (0·023 µg/g). Therefore, the mean Cd concentration found here reaches the maximum limit set by the European Union commission legislation. Cu was detected in all infant formulas. The highest concentration was determined in Brand 1 (9-12 months, seven samples) and found to be 2·637 (sd 1·928) µg/g. This value is much higher than the reference values set in the national and international standards. Based on the results achieved here, the estimated daily intake (EDI) and target hazard quotient values for all the metals in infant formulas were found lower than < 1. These findings suggest that the baby foods examined would not pose any health risk. The daily intakes exceeding the baby nutrition values recommended by the WHO would pose health risk since they would exceed the EDI levels.

Environmental risk factors associated with the survival, persistence, and thermal tolerance of Cronobacter sakazakii during the manufacture of powdered infant formula

Cronobacter sakazakii is an opportunistic foodborne pathogen of concern for foods having low water activity such as powdered infant formula (PIF). Its survival under desiccated stress can be attributed to its ability to adapt effectively to many different environmental stresses. Due to the high risk to neonates and its sporadic outbreaks in PIF, C. sakazakii received great attention among the scientific community, food industry and health care providers. There are many extrinsic and intrinsic factors that affect C. sakazakii survival in low-moisture foods. Moreover, short- or long-term pre-exposure to sub-lethal physiological stresses which are commonly encountered in food processing environments are reported to affect the thermal resistance of C. sakazakii. Additionally, acclimation to these stresses may render C. sakazakii resistance to antibiotics and other antimicrobial agents. This article reviews the factors and the strategies responsible for the survival and persistence of C. sakazakii in PIF. Particularly, studies focused on the influence of various factors on thermal resistance, antibiotic or antimicrobial resistance, virulence potential and stress-associated gene expression are reviewed.

Health risk assessment of some selected heavy metals in infant food sold in Wa, Ghana

Infants remain a high-risk group as far as exposure to toxic metals is concerned. The levels of lead (Pb), cadmium (Cd), nickel (Ni), chromium (Cr), antimony (Sb), mercury (Hg), and arsenic (As) in twenty-two (22) samples of baby foods and formulas were determined using inductively coupled plasma mass spectrometry. The concentrations in (mg/kg) of As, Cd, Cr, Hg, Mn, Ni, Pb, and Sb were in the ranges 0.006-0.057, 0.043-0.064, 0.113-0.33, 0.000-0.002, 1.720-3.568, 0.065-0.183, 0.061-0.368 and 0.017-0.1 respectively. Health risk assessment indices like the Estimated Daily Intake (EDI), Target Hazard Quotient (THQ), Cancer Risk (CR) and Hazard Index (HI) were calculated. EDI values of Hg, Cr, and As were below their recommended tolerable daily intake, that of Ni and Mn were lower in 95% of samples, and Cd was also lower in 50% of the samples. THQ values for As, Cd, Cr, Hg, Mn, Ni, and Pb were 0.32-3.21, 0.75-1.10, 0.65-1.94, 0.00-0.37, 0.21-0.44, 0.08-0.12 and 0.26-1.13 respectively. The CR values were greater than 10^-6, making them unacceptable for human consumption. HI values were between 2.68 and 6.83 (greater than 1), which implied that these metals are likely to pose non-carcinogenic health risks to infants.

Ethical Considerations for Hospital-Based Infant Feeding Support

I applied a systematic ethical decision-making approach to evaluate how health care professionals in hospital settings should provide infant feeding support after childbirth. Human milk is recommended as the optimal source of nutrition for infants because of the health benefits it provides for infants and their lactating parents. However, health consequences of insufficient oral intake in infants and psychological distress in the lactating parent may occur when infant feeding does not go according to plan. Infant feeding support should be provided in a way that is objective, sensitive, individualized, equitable, and supportive of autonomy and avoids harm. I provide recommendations for ethical infant feeding support that can be applied by individual health care professionals and on postpartum units in hospitals.

Food Safety and Invasive Cronobacter Infections during Early Infancy, 1961-2018

Contaminated powdered infant formula from opened containers is the most commonly identified transmission vehicle.

Invasive Cronobacter infections among infants are associated with severe neurologic disabilities and death. Early Cronobacter reports typically featured hospitalized and preterm infants and recognized contaminated powdered infant formula (PIF) as a transmission vehicle. To clarify recent epidemiology, we reviewed all cases of bloodstream infection or meningitis among infants that were reported to the Centers for Disease Control and Prevention and in the literature (1961–2018; n = 183). Most infants were neonates (100/150 [67%]); 38% (42/112) died, and 79% (81/102) had reported recent PIF consumption. In the final quarter of the study period (2004–2018), case counts were significantly higher (global average 8.7 cases/year); among US cases, significantly higher proportions occurred among full-term (56% [27/48]) and nonhospitalized (78% [42/54]) infants. PIF contamination, most commonly from opened containers, was identified in 30% (21/71) of investigations. Our findings reaffirm the need to promote safer alternatives for infant feeding, particularly among neonates.

Determination of 40 Elements in Powdered Infant Formulas and Related Risk Assessment

The aim of the study was to analyze all powdered infant formulas authorized and commercialized in Italy at the time of the study to measure the concentrations of 40 elements, and to estimate the infants’ intake of some toxic heavy metals for assessing possible related health risks. For this purpose, an optimized multi-element method was used through inductively coupled plasma mass spectrometry. Be, B, Al, Zr, Nb, Sb, Te, W, V, Cr and As concentrations were <LOD in more than 30% of samples. The levels of the other elements resulted to be very variable (more than 2000 µg g⁻¹ for Ca and K or less than 1 ng g⁻¹ for others). The results were similar to those reported by other European Union (EU) studies, but different from those recovered outside the EU. These differences should be eliminated to guarantee the right to health worldwide. The concentrations of Cd, Mn, Ni, Pb, and Zn in the infant formulas studied were always below the considered limits. However, it is important to check for potentially toxic elements in infant formulas to protect the health of this sensitive population. The data found in this study could be used as benchmark data for future research.

Genotypic and antimicrobial resistance characterizations of Cronobacter sakazakii isolated from powdered milk infant formula: A comparison between domestic and imported products

Cronobacter sakazakii, an opportunistic foodborne pathogen and a main cause of meningitis in neonates, is usually isolated from powdered milk infant formula (PMIF). At the present study, C. sakazakii were isolated from imported and domestically produced PMIF samples and identified by detection of ompA gene using real-time PCR SYBR green melting curve following the evaluation of antimicrobial susceptibility and genotyping of the isolates employing BOX-PCR and RAPD methods. We detected totally 5% contamination rate and a significantly higher prevalence of C. sakazakii in bulky imported domestically packaged PMIF samples. Also, our isolates were recognized as multidrug-resistant pathogen completely resistant to ampicillin and amoxicillin; and intermediately resistant to ciprofloxacin and tetracycline antimicrobials. Genotype clustering patterns of bulky imported and imported product isolates were identical by both genotyping methods. Far genetic relatedness of domestic isolate to other isolates and the reference strain indicated higher genetic diversity of the domestic isolate genome. Multidrug resistance and diverse population genetic make complicated situation for determination of strategies for infectious disease prevention.

Mixed milk feeding: a systematic review and meta-analysis of its prevalence and drivers

CONTEXT

Extensive literature is available on exclusive breastfeeding and formula-feeding practices and health effects. In contrast, limited and unstructured literature exists on mixed milk feeding (MMF), here defined as the combination of breastfeeding and formula feeding during the same period in term infants > 72 hours old (inclusion criterion).

OBJECTIVE

A systematic review and meta-analysis were performed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, on the global prevalence of MMF (primary outcome) and related drivers and practices (secondary outcomes).

DATA SOURCES

The search of MMF in generally healthy populations was conducted across 6 databases, restricted to publications from January 2000 to August 2018 in English, Spanish, French, and Mandarin.

DATA EXTRACTION

Two reviewers independently performed screenings and data extraction according to a priori inclusion and exclusion criteria.

DATA ANALYSIS

Of the 2931 abstracts identified, 151 full-text publications were included for data extraction and 96 of those were included for data synthesis (the majority of those were cross-sectional and cohort studies). The authors summarized data across 5 different categories (feeding intention prenatally, and 4 age intervals between > 72 hours and > 6-23 months) and 5 regional subgroups. The overall prevalence of MMF across different age intervals and regions varied between 23% and 32%; the highest rate was found for the age group 4-6 months (32%; 95% confidence interval, 27%-38%); regional comparisons indicated highest MMF rates in Asia (34%), North and South America (33%), and Middle East and Africa together (36%), using a random effects meta-analysis model for proportions. Some drivers and practices for MMF were identified.

CONCLUSION

MMF is a widespread feeding reality. A shared and aligned definition of MMF will help shed light on this feeding practice and evaluate its influence on the duration of total breastfeeding, as well as on infants' nutrition status, growth, development, and health status in the short and long terms. PROSPERO registration number CRD42018105337.

Multicenter Study of Cronobacter sakazakii Infections in Humans, Europe, 2017

Cronobacter sakazakii has been documented as a cause of life-threating infections, predominantly in neonates. We conducted a multicenter study to assess the occurrence of C. sakazakii across Europe and the extent of clonality for outbreak detection. National coordinators representing 24 countries in Europe were requested to submit all human C. sakazakii isolates collected during 2017 to a study center in Austria. Testing at the center included species identification by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, subtyping by whole-genome sequencing (WGS), and determination of antimicrobial resistance. Eleven countries sent 77 isolates, including 36 isolates from 2017 and 41 historical isolates. Fifty-nine isolates were confirmed as C. sakazakii by WGS, highlighting the challenge of correctly identifying Cronobacter spp. WGS-based typing revealed high strain diversity, indicating absence of multinational outbreaks in 2017, but identified 4 previously unpublished historical outbreaks. WGS is the recommended method for accurate identification, typing, and detection of this pathogen.