Psychosocial predictors of post-natal anxiety and depression: Using Structural Equation Modelling to investigate the relationship between pressure to breastfeed, health care professional support, post-natal guilt and shame, and post-natal anxiety and depression within an infant feeding context

High perceived pressure to breastfeed and poor perceived quality of health care professional support have been associated with early breastfeeding cessation, guilt, and shame. This is problematic because guilt and shame significantly predict post-natal anxiety and depression. No previous attempts have been made to provide quantitative evidence for relationships mapped between the post-natal social context, infant feeding method and post-natal emotional well-being. The current study aimed to empirically investigate aforementioned pathways. Structural equation modelling was applied to survey data provided online by 876 mothers. Guilt and shame both significantly predicted anxiety and depression. Poor health care professional support and high pressure to breastfeed increased anxiety and depression, and these effects were explained by indirect pathways through increases in guilt and shame. Formula feeding exclusivity was negatively correlated with post-natal anxiety symptoms. This finding may be explained by feelings of relief associated with observed infant weight gain and being able to share infant feeding responsibilities others e.g., with one's partner. This relationship was counterbalanced by an indirect pathway where greater formula feeding exclusivity positively predicted guilt, which increased post-natal anxiety score. While guilt acted as mediator of infant feeding method to increase post-natal depression and anxiety, shame acted independently of infant feeding method. These identified differences provide empirical support for the transferability of general definitions of guilt (i.e., as remorse for having committed a moral transgression) and shame (i.e., internalisation of transgressive remorse to the self), to an infant feeding context. Recommendations for health care practitioners and the maternal social support network are discussed.

Evidence from a Choice Experiment in Consumer Preference towards Infant Milk Formula (IMF) in the Context of Dairy Revitalization and COVID-19 Pandemic

China is the largest global consumer of infant milk formula (IMF). Chinese consumer preferences towards IMF have evolved over time but have also been rocked in recent years by COVID-19 with major implications for the IMF industry, globally and within China. This study is the first to document parents’ preferences toward IMF since the outbreak. We used novel methods to do so, through an online choice experiment of 804 participants that included risk perceptions and socio-demographic variables. Our study finds that Chinese parents continue to prioritize quality and safety attributes of IMF represented by functional ingredients, organic labelling and traceability information. Notably, it also finds greatly increased confidence in Chinese domestically produced IMF and an underlying preference away from expensive products. This implies that the era of ‘go for foreign’ and ‘go for the most expensive’ in IMF purchasing may be coming to an end. The shift in sentiment is driven by the longer-term revitalization of the Chinese dairy industry, accelerated by COVID-19. Understanding these trends will be of major benefit to both Chinese producers and non-Chinese exporters of IMF.

Violations of International Code of Breast-milk Substitutes (BMS) in commercial settings and media in Bangladesh

The International Code of Marketing of Breast‐milk Substitutes (BMS) instituted to protect breastfeeding against unethical marketing, has been adopted by many countries, including Bangladesh. Despite national adoption, evidence suggests violations occur and inadequate BMS Code implementation is an issue. The study aimed to assess violations of the International BMS Code and the national ‘Breast‐milk Substitutes, Infant Foods, Commercially Manufactured Complementary Foods and the Accessories Thereof (Regulation of Marketing) Act, 2013’ of Bangladesh in commercial settings (retail outlets and media) in Bangladesh, for different types of milk, bottles, and teats using a standardized Network for Global Monitoring and Support for Implementation of the Code and Subsequent relevant World Health Assembly Resolutions (NetCode) protocol. This cross‐sectional quantitative study was conducted in Bangladesh from January to September 2018 in Dhaka, Chattogram, and Sylhet cities. Descriptive statistics were reported and χ² tests were conducted to assess differences between categorical variables of interest. Data were analysed using SPSS version 20. In retail outlets, there were higher proportion of violations observed in Dhaka than in Sylhet and Chattogram (p < 0.001). Significantly greater proportion of violations in product labels occurred among products sold without local distributors compared to others (p < 0.05); violations were higher among “other milk” for children aged 0 to <36 months compared to formulas and growing‐up milk (p < 0.05). Among media channels, internet clips had significantly higher proportions of violations compared to television, radio and newspaper (p < 0.001). BMS Code violations were prevalent in product labels and promotion of products through retail outlets. The study findings highlight the need for specific multisectoral strategies for better enforcement of BMS Code and points to the need for periodic assessment of Code violations.

This is the first known study documenting violations in retail outlets, online stores, and media using the standard NetCode protocol in Bangladesh.

BMS Code violations were high in retail stores and were more prevalent in the capital city compared to others.

Violations were significantly higher in the internet compared to radio, television, and newspapers, highlighting the need for strengthening the monitoring of internet‐based promotions.

It is essential to allocate resources to sensitize retail stores to the BMS Code to enhance the implementation of the law.

Multiclass and multi-residue screening of mycotoxins, pharmacologically active substances, and pesticides in infant milk formulas through ultra-high-performance liquid chromatography coupled with high-resolution mass spectrometry analysis

Infant milk formulas are designed to substitute human milk when breastfeeding is unavailable. In addition to human milk and milk-derived products, these formulas can be a vehicle of contaminants. In this work, a multiclass method based on the QuEChERS (quick, easy, cheap, effective, rugged, and safe) approach was developed for the simultaneous determination of contaminants (n = 45), including mycotoxins and veterinary drug residues, occurring in infant milk formulas. By using an ultra-high-performance liquid chromatography quadrupole-Orbitrap coupled with high-resolution mass spectrometry analysis (UHPLC-Q-Orbitrap HRMS; Thermo Fisher Scientific), further retrospective analysis of 337 contaminants, including pesticides, was achieved. The method was validated in accordance with European regulations and applied for the analysis of 54 infant milk samples. Risk assessment was also performed. Dexamethasone was detected in 16.6% of samples (range: 0.905-1.131 ng/mL), and procaine benzyl penicillin in 1 sample at a concentration of 0.295 ng/mL. Zearalenone was found in 55.5% of samples (range: 0.133-0.638 ng/mL) and α-zearalenol in 16.6% of samples (range: 1.534-10.408 ng/mL). Up to 49 pesticides, 11 veterinary drug residues, and 5 mycotoxins were tentatively identified via retrospective analysis based on the mass spectral library. These findings highlight the necessity of careful evaluation of contaminants in infant formulas, considering that they are intended for a vulnerable part of the population.

Mothers' and health workers' exposure to breastmilk substitutes promotions in Abidjan, Côte d'Ivoire

Marketing of breastmilk substitutes (BMS) continues to undermine breastfeeding globally, and low income countries experiencing rapid economic growth are especially vulnerable as expanding BMS markets. The objective of the study was to understand the prevalence of exposure to BMS promotions among mothers of children 0–23 months, the frequency and type of contacts between BMS companies and health workers and the presence of educational/informational materials and branded equipment associated with such companies in health facilities in Abidjan using the World Health Organization's NetCode protocol. The methods included structured interviews with health workers and mothers and observations of equipment/materials in a sample of 42 facilities, 330 mothers and 129 health workers. Descriptive statistics were produced, and chi‐squared tests were used to assess differences by child age and facility type. Forty‐three per cent of mothers were advised to feed BMS products in the past 6 months, with a significantly higher percentage of mothers of older children (6–23 months) advised compared to infants 0–5 months. Two thirds (66%) of mothers had seen promotions outside of facilities. Among health workers, 63% were contacted by BMS companies, and only 8% were familiar with the International Code of Marketing of BMS. Differences were found between public/private facilities in the types of requests BMS companies made to health workers. Strong actions are needed in Côte d'Ivoire to prevent BMS promotion in the health system, including increasing health workers' knowledge of the International Code and national regulations, monitoring violations and reaching mothers and families to promote optimal breastfeeding practices.

Human Milk Concentrations of Minerals, Essential and Toxic Trace Elements and Association with Selective Medical, Social, Demographic and Environmental Factors

This study aims to quantify concentrations of minerals and trace elements in human milk (HM) and infant formula (IF) and evaluate associations with medical, social, environmental, and demographic variables. A prospective, case series study of 170 nursing mothers was made. HM samples were obtained from full-term (colostrum, intermediate and mature HM) and preterm (mature HM) mothers. Variables of interest were assessed by a questionnaire. For comparison, IF samples (n = 30) were analyzed in a cross-sectional study. Concentrations of 35 minerals, essential and toxic trace elements were quantified, 5 for the first time: thallium in HM and IF; strontium in preterm HM; and gallium, lithium and uranium in IF. In preterm and full-term HM, levels of selenium (p < 0.001) were significantly lower than recommended and were associated with low birth weight (p < 0.002). Cesium and strontium concentrations were significantly higher than recommended (p < 0.001). Associations were observed between arsenic and residence in an urban area (p = 0.013), and between lead and smoking (p = 0.024) and well-water consumption (p = 0.046). In IF, aluminum, vanadium, and uranium levels were higher than in HM (p < 0.001); uranium, quantified for the first time, was 100 times higher in all types of IF than in HM. Our results indicate that concentrations of most trace elements were within internationally accepted ranges for HM and IF. However, preterm infants are at increased risk of nutritional deficiencies and toxicity. IF manufacturers should reduce the content of toxic trace elements.

Mildly Pasteurized Whey Protein Promotes Gut Tolerance in Immature Piglets Compared with Extensively Heated Whey Protein

Human milk is the optimal diet for infant development, but infant milk formula (IMF) must be available as an alternative. To develop high-quality IMF, bovine milk processing is required to ensure microbial safety and to obtain a protein composition that mimics human milk. However, processing can impact the quality of milk proteins, which can influence gastro-intestinal (GI) tolerance by changing digestion, transit time and/or absorption. The aim of this study was to evaluate the impact of structural changes of proteins due to thermal processing on gastro-intestinal tolerance in the immature GI tract. Preterm and near-term piglets received enteral nutrition based on whey protein concentrate (WPC) either mildly pasteurized (MP-WPC) or extensively heated (EH-WPC). Clinical symptoms, transit time and gastric residuals were evaluated. In addition, protein coagulation and protein composition of coagulates formed during in vitro digestion were analyzed in more detail. Characterization of MP-WPC and EH-WPC revealed that mild pasteurization maintained protein nativity and reduced aggregation of β-lactoglobulin and α-lactalbumin, relative to EH-WPC. Mild pasteurization reduced the formation of coagulates during digestion, resulting in reduced gastric residual volume and increased intestinal tract content. In addition, preterm piglets receiving MP-WPC showed reduced mucosal bacterial adherence in the proximal small intestine. Finally, in vitro digestion studies revealed less protein coagulation and lower levels of β-lactoglobulin and α-lactalbumin in the coagulates of MP-WPC compared with EH-WPC. In conclusion, minimal heat treatment of WPC compared with extensive heating promoted GI tolerance in immature piglets, implying that minimal heated WPC could improve the GI tolerance of milk formulas in infants.

Correlating Volatile Lipid Oxidation Compounds with Consumer Sensory Data in Dairy Based Powders During Storage

Lipid oxidation (LO) is a recognised problem in dairy powders due to the formation of volatile odour compounds that can negatively impact sensory perception. Three commercial dairy powders, fat-filled whole milk powder (FFWMP), skim milk powder (SMP), and infant milk formula (IMF), stored under different conditions (21 °C, 37 °C, or 25 °C with 50% humidity), were evaluated by consumer acceptance studies, ranked descriptive sensory analysis, and LO volatile profiling using headspace solid phase microextraction gas chromatography mass spectrometry (HS-SPME GCMS) over 16 weeks. Significant (p = 0.001) differences in the concentration of LO compounds and sensory perception were evident between sample types in the different storage conditions. The sensory acceptance scores for FFWMP and SMP remained stable throughout storage in all conditions, despite the increased perception of some LO products. The IMF sample was perceived negatively in each storage condition and at each time point. Overall increases in hexanal, heptanal, and pentanal correlated with “painty”, “oxidised”, “cooked”, and “caramelised” attributes in all samples. The concentration of some LO volatiles in the IMF was far in excess of those in FFWMP and SMP. High levels of LO volatiles in IMF were presumably due to the addition of polyunsaturated fatty acids (PUFA) in the formulation.

A free amino acid-based diet partially prevents symptoms of cow's milk allergy in mice after oral sensitization with whey

BACKGROUND

Amino acid-based formulas (AAFs) are used for the dietary management of cow's milk allergy (CMA). Whether AAFs have the potential to prevent the development and/or symptoms of CMA is not known.

OBJECTIVE

The present study evaluated the preventive effects of an amino acid (AA)-based diet on allergic sensitization and symptoms of CMA in mice and aimed to provide insight into the underlying mechanism.

METHODS

C3H/HeOuJ mice were sensitized with whey protein or with phosphate-buffered saline as sham-sensitized control. Starting 2 weeks before sensitization, mice were fed with either a protein-based diet or an AA-based diet with an AA composition based on that of the AAF Neocate, a commercially available AAF prescribed for the dietary management of CMA. Upon challenge, allergic symptoms, mast cell degranulation, whey-specific immunoglobulin levels, and FoxP3+ cell counts in jejunum sections were assessed.

RESULTS

Compared to mice fed with the protein-based diet, AA-fed mice had significantly lower acute allergic skin responses. Moreover, the AA-based diet prevented the whey-induced symptoms of anaphylaxis and drop in body temperature. Whereas the AA-based diet had no effect on the levels of serum IgE and mucosal mast cell protease-1 (mMCP-1), AA-fed mice had significantly lower serum IgG2a levels and tended to have lower IgG1 levels (P = .076). In addition, the AA-based diet prevented the whey-induced decrease in FoxP3+ cells. In sham-sensitized mice, no differences between the two diets were observed in any of the tested parameters.

CONCLUSION

This study demonstrates that an AA-based diet can at least partially prevent allergic symptoms of CMA in mice. Differences in FoxP3+ cell counts and serum levels of IgG2a and IgG1 may suggest enhanced anti-inflammatory and tolerizing capacities in AA-fed mice. This, combined with the absence of effects in sham-sensitized mice indicates that AAFs for the prevention of food allergies may be an interesting concept that warrants further research.

Implementation of the International Code of Marketing of Breastmilk Substitutes in the Eastern Mediterranean Region

BACKGROUND

Optimal breastfeeding practices and appropriate complementary feeding improve child health, survival and development. The countries of the Eastern Mediterranean Region have made significant strides in formulation and implementation of legislation to protect and promote breastfeeding based on The International Code of Marketing of Breast-milk Substitutes (the Code) and subsequent relevant World Health Assembly resolutions.

AIM

To assess the implementation of the Code in the Region.

METHODS

Assessment was conducted by the World Health Organization (WHO) Regional Office for the Eastern Mediterranean using a WHO standard questionnaire.

RESULTS

Seventeen countries in the Region have enacted legislation to protect breastfeeding. Only 6 countries have comprehensive legislation or other legal measures reflecting all or most provisions of the Code; 4 countries have legal measures incorporating many provisions of the Code; 7 countries have legal measures that contain a few provisions of the Code; 4 countries are currently studying the issue; and only 1 country has no measures in place. Further analysis of the legislation found that the text of articles in the laws fully reflected the Code articles in only 6 countries.

CONCLUSION

Most countries need to revisit and amend existing national legislation to implement fully the Code and relevant World Health Assembly resolutions, supported by systematic monitoring and reporting.

Very low prevalence of iron deficiency among young French children: A national cross-sectional hospital-based survey

Although iron deficiency (ID) is considered the most frequent micronutrient deficiency in industrialized countries and is associated with impaired neurodevelopment when occurring in early years, accurate recent estimations of its prevalence are lacking. Our objective was to estimate ID prevalence and associated sociodemographic markers in young children in France. The Saturn-Inf national cross-sectional hospital-based survey recruited 3,831 French children <6 years old between 2008 and 2009 to assess lead poisoning prevalence and to establish a biobank. This secondary analysis measured serum ferritinemia (SF) in sera kept frozen at -80 °C for children with sufficient serum aliquots and C-reactive protein <10 mg/L. For the 657 participating children (17% of the Saturn-Inf study), the median age was 3.9 years (interquartile range: 2.2-5.1); 52% were boys. The median SF was 44 μg/L (interquartile range: 28-71). ID prevalence was 2.8% (95% confidence interval [1.7, 4.7]) and 3.2% (95% confidence interval [2.0, 5.1]) with an SF threshold of 10 and 12 μg/L, respectively. Low SF was significantly associated (p < .05) with mother being a migrant (32 vs. 45 μg/L for a mother born in France) or unemployed (37 vs. 50 μg/L for a mother employed). In this first national cross-sectional hospital-based study in France, ID prevalence was much lower than that in other French and European studies performed in underprivileged populations but close to the lowest values observed in other population-based studies in Europe.

Acute and Chronic Effects of Dietary Lactose in Adult Rats Are not Explained by Residual Intestinal Lactase Activity

Neonatal rats have a high intestinal lactase activity, which declines around weaning. Yet, the effects of lactose-containing products are often studied in adult animals. This report is on the residual, post-weaning lactase activity and on the short- and long-term effects of lactose exposure in adult rats. Acutely, the postprandial plasma response to increasing doses of lactose was studied, and chronically, the effects of a 30% lactose diet fed from postnatal (PN) Day 15 onwards were evaluated. Intestinal lactase activity, as assessed both in vivo and in vitro, was compared between both test methods and diet groups (lactose vs. control). A 50%–75% decreased digestive capability towards lactose was observed from weaning into adulthood. Instillation of lactose in adult rats showed disproportionally low increases in plasma glucose levels and did not elicit an insulin response. However, gavages comprising maltodextrin gave rise to significant plasma glucose and insulin responses, indicative of a bias of the adult GI tract to digest glucose polymers. Despite the residual intestinal lactase activity shown, a 30% lactose diet was poorly digested by adult rats: the lactose diet rendered the animals less heavy and virtually devoid of body fat, whereas their cecum tripled in size, suggesting an increased bacterial fermentation. The observed acute and chronic effects of lactose exposure in adult rats cannot be explained by the residual intestinal lactase activity assessed.

Decoupling macronutrient interactions during heating of model infant milk formulas

Understanding macronutrient interactions during heating is important for controlling viscosity during infant milk formula (IMF) manufacture. Thermal behavior of macronutrients (casein, whey, lactose, fat) was studied, in isolation and combination, over a range of concentrations. Addition of phosphocasein to whey protein solutions elevated denaturation temperature (Td) of β-lactoglobulin and the temperature at which viscosity started to increase upon heating (Tv). Secondary structural changes in whey proteins occurred at higher temperatures in dispersions containing phosphocasein; the final extent of viscosity increase was similar to that of whey protein alone. Addition of lactose to whey protein solutions delayed secondary structural changes, increased Td and Tv, and reduced post heat treatment viscosity. This study demonstrated that heat-induced changes in IMF associated with whey protein (denaturation, viscosity) are not only a function of concentration but are also dependent on interactions between macronutrients.

GI symptoms in infants are a potential target for fermented infant milk formulae: a review

Besides pre- and pro-biotic-containing infant formulae, fermented infant formulae are commonly used to relieve or prevent symptoms of gastrointestinal (GI) discomfort in young infants. During the fermentation process in cow's milk-based formulae, the beneficial bacteria modulate the product by forming several beneficial compounds, which contribute to the alleviation of the symptoms observed. This review summarizes the clinical evidence on the impact of fermented infant formulae on common pediatric GI-symptoms. The potential mechanisms involved are discussed: i.e., the lactose and protein (in-) digestibility, effects on gastric emptying and gut transit and modulation of the colonic microbiota. Although initial evidence indicates a beneficial effect of fermented formulae on GI discomfort in newborns, validation and confirmation of the clinical proof obtained so far is warranted, as well as further research to (more fully) understand the mode of action.