IBFAN Asia Presentations Reading List

Maureen MinchinAllergies, Bottle Feeding, breastmilk, Child Health, Commentary, Complementary Feeding, Food Intolerance, Growth, Immunology, Infant Formula, Infant Health, Lactation, Maternal Health, Microbiome, Weaning

Basic resource:

Milk Matters: infant feeding and immune disorder, is also available as two inexpensive e-books, Infant formula and Modern Epidemics (the science and reality of artificial feeding) and Crying Babies and Food in the Early Years.No other book contains what this does. You need access to this.

My Milk Hypothesis is available online in shorter forms:

My website is www.infantfeedingmatters.comThere you will find various useful posts and book reviews, with some links below.. Read critically. The following references also need critical reading, as some show clear evidence of the cultural assumptions that enable WEIRD feeding practices to continue, even as the authors outline its harms and risks.

Next are excerpts from some papers that cover topics I hope to touch on. I’ve given the DOI numbers so you can easily access and read the whole or at least the abstract. Simply go to the doi site https://dx.doi.organd paste that number in, and so go to the article or abstract. If that prefix is given,  you can click on (or copy and paste the link) to go direct to the articles listed.  A PMID number allows you to find it in PubMed, another source all here probably are aware of.

WHY MILK MATTERS

On my website, see the post, http://infantfeedingmatters.com/evidence-streams-in-infant-feeding for an overview of the evidence for why feeding matters

Infant Feeding and the Developmental Origins of Chronic Disease in the CHILD Cohort: Role of Human Milk Bioactives and Gut Microbiota.Breastfeed Med 2019,  https://doi.org/10.1089/bfm.2019.0029 PMID:30985197 MM: A really good brief summary overview of this aspect if you can access.

Even to the brain: yes breastmilk stem cells do transfer to organs of offspring. http://milk genomics.org/issue/splash-milk-science-update-February-2019/ “using a TD tomato mouse model, we were able to demonstrate that milk stem cells, as well as immune cells, survive the neonatal gut, migrating to the blood, and from there travel and integrate into various organs of the suckling pups, including the thymus, liver, pancreas, spleen, kidneys and the brain. There they actually seem to turn into specialised cells of each specific organ. The model was based on mouse mothers who ubiquitously expressed a red fluorescent gene in every cell of the body, including in their milk cells. These mothers fostered pups that did not express it at all. So any red fluorescing cell in the pup’s body had to come from the milk.

A new study by Aydin and colleagues use …a different mouse model in which mouse mothers ubiquitously expressed the green fluorescent protein, whereas the pups they foster did not express it at all. This study.. [demonstrated] that milk stem cells indeed survive inside the young’s gastrointestinal tract, and from there they are transferred into the blood and brain of the young. There they are coaxed by specific brain micro-environmental cues to become specialised brain cells of two types: neuronal and glial, the two main brain cell types.

This phenomenon of transfer and integration of foreign cells into an organism is called micro-chimerism, and transfer of maternal cells to the young can happen not only in utero but also during lactation.… All evidence thus far supports the notion that these stem cells become active and functioning parts of the body of the young. In addition to stem cells the breastfed infant receives immune cells from mother’s milk. Both these two milk cell types have been shown to home also in the infant thymus among other organs. The thymus is responsible for the maturation of our immune cells.” [MM: and on average the formula fed baby’s thymus is just half the size of the breastfed baby’s, just one of many differences in infant organ size and structure. In pregnancy the microchimeric transfer is two-way, with infant cells shown to survive up to 62years so far in a mother, and presumably in the child as well. Mothers and their children are truly linked for life.]

Exclusive breastfeeding in hospital predicts longer breastfeeding duration in Canada: Implications for health equityBirth 2018 PMID:29498088; DOI:10.1111/birt.12345 Exclusive breastfeeding in hospitalis associated with longer breastfeeding duration, particularly among women of lower socioeconomic status. Initiatives that support exclusive breastfeeding of newborns in hospital could improve long-term breastfeeding rates and help reduce health inequities arising in early life.” {7vs11 months; 16 vs 35% reduction Cited study said 89% US infants are formula exposedin hospital.}

MM: Formula exposure most harms groups already disadvantaged by racism and poverty. Early-life feeds do harm in many ways, and to the most vulnerable. The importance of hospital exposure is why companies have long bribed hospitals to carry their brand. See my post at https://infantfeedingmatters.com/elf-feeds-a-fairy-story-analysed/

Human Milk Oligosaccharide Concentrations Are Associated with Multiple Fixed and Modifiable Maternal Characteristics, Environmental Factors, and Feeding Practices.J Nutr 2018;  PMID:30247646 DOI: 10.1093/jn/nxy175Online at https://academic.oup.com/jn/article/148/11/1733/5105883

“Human milk oligosaccharides (HMOs) shape the developing gut microbiome and influence immune function”“HMO concentrations vary widely between mothers and are associated with multiple characteristics beyond genetic Secretor status, as well as feeding practices and environmental factors. Further research is warranted to determine how these associations affect infant health.”

MM: It may be that the differences are adaptations to particular infant/environment needs, and there is no one best pattern for women’s milk. We need to be careful not to give the impression that “difference” means some milk is better, before that has beenproved. Women are all too ready to believe that while breastfeeding is great, their breastmilk is somehow defective. Note also that maybe 150+ human milk oligosaccharides exist only in breastmilk; the 3-5 analogues being put into infant formulas should be called Synthetic Oligosaccharides, or Plant-Derived Oligosaccharides depending on origins. Using the word “human”  for synthesised plant-based analogues is inaccurate. Calling bovine-based additives/supplements “human milk fortifiers” has promoted unnecessary use and caused harm. A global campaign is needed to get full disclosure of all formula additives, and accurate detailed labelling, and prosecution under consumer protection law for false and misleading marketing. While it would be great to get the Code enacted as law, we don’t need to wait till then for legal action against false and misleading marketing in countries which have those laws already. WABA, WBTi, please? Such a campaign would have the support of many formula feeding parents currently being misled. In WEIRD nations that would create a much broader group demanding change, than would  support specific legislation targetting infant formula marketing.  

Composition and variation of the human milk microbiota are influenced by maternal and early-life factors. Cell Host Microbe2019. doi: 10.1016/j.chom.2019.01.011. MM: Excellent overview discussed in https://www.gutmicrobiotaforhealth.com/en/a-new-study-sheds-light-on-maternal-and-infant-factors-that-shape-breast-milk-microbiome/

Breast-feeding and delivery mode modify the association between maternal atopy and childhood allergic outcomes https://doi.org/10.1016/j.jaci.2018.08.012 “A family history of allergy, especially maternal allergy, is associated with an increased likelihood of sensitization and allergic diseases during childhood.”

“We found that maternal atopy is primarily a risk factor among children born via C-section and in nonexclusively breast-fed children, with early breast-feeding and vaginal delivery mitigating the transmission of atopy from mother to child.” “Our analyses suggest that vaginal delivery and exclusive breast-feeding in combination significantly modify the association between maternal atopy and atopic outcomes and suggest that the excess risk of allergy in offspring due to maternal atopy depends on these exposures.” “These results may be informative in regard to potential targeted prevention strategies in high-risk offspring of atopic mothers, though further studies will be necessary to determine the biological mechanisms behind these protective effects.”

Association of Exposure to Formula in the Hospital and Subsequent Infant Feeding Practices With Gut Microbiota and Risk of Overweight in the First Year of Life. JAMA Pediatrics 2018. DOI:10.1001/jamapediatrics.2018.2205 PMID:29868719 “Formula feeding appears to stimulate changes in microbiota that are associated with overweight, whereas other complementary foods do not. Subtle microbiota differences emerge after brief exposure to formula in the hospital.” 30.9% of EBF at 3 months MM: BF for more than 3 months mitigates these. Again, early limited feeds and ‘supplementing’ with formula do damage. See previous post. https://infantfeedingmatters.com/elf-feeds-a-fairy-story-analysed/

Intranasal breast milk for premature infants with severe intraventricular hemorrhage-an observation.Eur J Pediatr2019; doi:10.1007/s00431-018-3279-7PMID:30386923  “At our tertiary neonatal center, more than 85% VLBW infants are fed with breast milk. We offered a few drops of additional breast milk intranasally to preterm VLBW infants after diagnosis of severe intraventricular hemorrhage grade 3/4 in the form of a compassionate use following parental informed consent. A positive outcome in the cerebral ultrasound courses of these patients was observed.” “The hypothesis is generated that early intranasal application of breast milk could have a beneficial effect on neurodevelopment in preterm infants.”

Abrupt [breast] involution induces inflammation, estrogenic signaling, and hyperplasia linking lack of breastfeeding with increased risk of breast cancer.Breast Cancer Res.2019 PMID:31315645DOI:10.1186/s13058-019-1163-7 “A large collaborative analysis of data from 47 epidemiological studies concluded that longer duration of breastfeeding reduces the risk of developing breast cancer… We report here for the first time that forced or abrupt involution of the mammary glands following pregnancy and lack of breastfeeding results in expansion of luminal progenitor cells, higher inflammation, proliferation, and ductal hyperplasia, a known risk factor for developing breast cancer.” MM: Mothers  considering formula feeding need to know this. Not breastfeeding damages them, as well as baby. And abrupt weaning at any age may be harmful: gradual involution over time is natural.

Breastfeeding Initiation Associated With Reduced Incidence of Diabetes in Mothers and Offspring Obstetrics & Gynecology2016 DOI: 10.1097/AOG.0000000000001689 PMID:27741196 Breastfeeding initiation was recorded in 83% of non–First Nations mothers and 56% of First Nations mothers (P<.001). Breastfeeding initiation was associated with a reduced risk of incident (later developed) diabetes in non–First Nations mothers without GDM (hazard ratio [HR] 0.73 [or −27% of risk], 95% confidence interval [CI] 0.68–0.79), non–First Nations mothers with GDM (HR 0.78 or −22% of risk, CI 0.69–0.89), First Nations mothers without GDM (HR 0.89 or −11% of risk, CI 0.81–0.98), and First Nations mothers with GDM (HR 0.82 or −18% of risk, CI 0.73–0.92) with 24 years of follow-up or less. With 24 years of follow-up or less, breastfeeding initiation was associated with a 17% lower risk of youth-onset type 2 diabetes in offspring (HR 0.83, CI 0.69–0.99, P=.038). The association between breastfeeding initiation and subsequent diabetes in mothers and offspring was independent of family income, rural residence, First Nations status, GDM, parity, gestational hypertension, and age of the mother. MM: It would be interesting to know if it was related to the mother’s own infantfeeding history. Does it protect less when the mother was herself formula fed? Does the rate increase with each generation exposed in early life?And remember, if we take breastfeeding as the norm and then calculate increased risk, the figures are higher.

Early introduction of food other than breastmilk increases risks for mothers and babies alike. See: https://infantfeedingmatters.com/what-3-4-months-means/

Review shows that donor milk does not promote the growth and development of preterm infants as well as maternal milk.Acta Paediatr 2019. PMID:30565323  DOI:10.1111/apa.14702 “Many of the components in raw maternal breastmilk were lacking in pasteurised donor milk, which was inferior in promoting the growth and development of very preterm infants.”

Breastmilk cell trafficking induces microchimerism-mediated immune system maturation in the infant. PAI 2018 PMID: 29197124 DOI: 10.1111/pai.12841 “Initiating breastfeeding within the first hour of life confers an important benefit in terms of child mortality and severe morbidity. Intestinal permeability to ingested macromolecules and immunoglobulins is limited to the first days of human life.” …”the timing of early initiation of the practice of breastfeeding also ensures that the infant has access to unique early benefits of breastmilk. The early infant intestinal mucosa is an open route to milk immune cells. This open gate closes, whether by maternal‐mediated factors through variation in milk composition and/or by infant‐mediated factors that impact intestinal mucosal changes, in part dependent on infant food source, in the very early post‐partum period. A better understanding of this window of opportunity for human milk immune cell transfer may have important implications for early post‐partum care of mothers and their newborns and for longer term child’s health.”… …” breastfeeding initiation within the first hour of life has such tremendous impact on the reduction in infant mortality.“ Specifically, this mechanism termed maternal microchimerism (MMC) is the transfer and persistent nesting of maternal cells from early breastmilk to infant intestinal mucosal tissue, and from there, perhaps to other infant immune tissues. Data and physiology support the idea that these maternal milk cells are transmitted to the breastfed infant especially during the early breastfeeding phase, a period during which the highest concentration of milk leukocytes and stem cells is present in colostrum and early breastmilk”… “Trafficking of maternal milk stem cells, progenitors, and immunologically active cells from breastmilk may favor implantation of these living cells of maternal origin in the infant’s tissues that may be involved in the effector immune response, in tissue repair and in the regulation of the neonatal immune response and immune tolerance. Long‐term MMC may be one of the major mechanisms used to perpetuate the functions of cells of maternal origin in infant tissues. It may tentatively involve stem cells that are highly plausible candidates due to their absence of expression of surface MHC class 1 and class 2 determinants, immune cells, and other immune cell types in breastmilk. As this microchimerism mechanism implies prolonged infant immune tolerance to maternal cells, MMC may confer lifelong benefits such as immune protection against infectious agents, inflammation, cancer, and favor transplant tolerance”… “While EBF for 6 months is the universal recommendation, for various reasons not all infants are fed this way. “Early and any” breastfeeding initiated in the maternity ward may be better than no breastfeeding at all, even if for any reason, the mother later chooses to feed her infant differently.”

MM: The above article should be read by any who question skin to skin contact and ad lib suckling in the first days of life.

Meta-analysis of effects of exclusive breastfeeding on infant gut microbiota across populations.Nat Commun 2018 PMID:30301893 DOI:10.1038/s41467-018-06473-x..a meta-analysis of seven microbiome studies (1825 stool samples from 684 infants) to compare the gut microbiota of non-EBF and EBF infants across populations. In the first 6 months of life, gut bacterial diversity, microbiota age, relative abundances of Bacteroidetes and Firmicutes, and predicted microbial pathways related to carbohydrate metabolism are consistently higher in non-EBF than in EBF infants, whereas relative abundances of pathways related to lipid metabolism, vitamin metabolism, and detoxification are lower. Variation in predicted microbial pathways associated with non-EBF infants is larger among infants born by Caesarian section than among those vaginally delivered. Longer duration of exclusive breastfeeding is associated with reduced diarrhea-related gut microbiota dysbiosis. Furthermore, differences in gut microbiota between EBF and non-EBF infants persist after 6 months of age. Our findings elucidate some mechanisms of short and long-term benefits of exclusive breastfeeding across different populations.

The Prebiotic and Probiotic Properties of Human Milk: Implications for Infant Immune Development and Pediatric Asthma.Front Pediatr 2018, PMID:30140664 DOI:10.3389/fped.2018.00197

..the latest evidence, mechanisms and hypotheses for the synergistic and/or additive effects of milk microbiota and HMOs in protecting against pediatric asthma. “Breastfeeding profoundly influences the infant gut microbiota, and emerging evidence indicates that divergence from this evolutionarily conserved process can alter immune system maturation and influence asthma development.”MM: Good diagram

Early-life antibiotic exposure and childhood food allergy: a systematic review. J Allergy Clin Immunol 2019 https://doi.org/10.1016/j.jaci.2019.08.001

MM: Yes, effects: causal? Probably.

Major problem is western misunderstandings of allergy: see Reconciling breast-feeding and early food introduction guidelines in the prevention and management of food allergy. J All Clin Immunol 2019 DOI:10.1016/j.jaci.2019.06.004

PMID:31395151 “Ultimately, feeding guidelines are interpreted and acted on by an infant’s caregiver in the context of cultural, societal, and economic circumstances and expectations. Although wording can differ slightly regarding timing of introduction to solid foods and thus the implied length of exclusive breast-feeding, small differences in wording are confusing. We call for the development of infant feeding guidelines for allergy prevention that are harmonized and free from commercial and vested interest.” MM: Some good points, but standard hospital-based allergist mistakes as well: not good about managing maternal diet changes; doesn’t critique EAT or LEAP;  equivocal about BF as allergy prevention because unaware of the importance of true from birth EBF, eg, or the intergenerational impacts of past AF. But better than much allergist advice.

Blog posts include  https://infantfeedingmatters.com/leaping-to-conclusions-about-infant-diet/

https://infantfeedingmatters.com/im-going-nuts-about-peanuts-or-are-other-people/

https://infantfeedingmatters.com/four-months-or-six-or-neither-when-to-widen-the-milk-diet/

I intend to update the peanut blog…

Inherited non-genetic influences on the gut microbiome and immune system.Birth Defects Research 2018 https://doi.org/10.1002/bdr2.1436

“Recent observations suggest that maternal factors encountered both in utero and after birth can directly or indirectly impact the development of the offspring’s gut microbiome and immune system. Here, we discuss how these nongenetic maternal influences can have long‐term effects on the progeny’s health.” “Our parents give us more than genes.” MM: we inherit more than genes, and how our genes are expressed can be inherited. The Milk Hypothesis: we all begin in our grandmothers’ wombs, and damage will compound through generations.

COMPLEMENTARY FOODS, OBESITY POST 6 MONTHS

Infant Feeding and Weight Gain: Separating Breast Milk From Breastfeeding and Formula From Food. Pediatrics https://doi.org/10.1542/peds.2018-1092;PMID:30249624.  “Breastfeeding is inversely associated with weight gain velocity and BMI. [MM: ie, formula fed babies get fatter faster.] These associations are dose dependent, partially diminished when breast milk is fed from a bottle, and substantially weakened by formula supplementation after the neonatal period.”

Quantifying and Interpreting the Association between Early-Life Gut Microbiota Composition and Childhood Obesity. MBio 2019 DOI: 10.1128/mBio.01751-18 “there is evidence to support the idea that environmentally derived microbes that colonize during a key time in development could have consequential long-term programming effects. Furthermore, although the association between infant gut microbiota and childhood BMI became stronger as the infant aged, we did see associations within the first months of life as well, and it is unlikely that this is driven by lifestyle factors because the majority of babies in this cohort were exclusively breastfed, limiting the influence of diet, and physical activity would not yet be a factor at this age. There is also evidence that many of the taxa associated with BMI in our findings have immune or metabolic modulating effects, such as early proteobacteria,Faecalibacterium prausnitzii, and Bacteroides fragilis. We have limited understanding of the temporal interplay between gut microbiota taxa and the developing immune and metabolicsystems in early life, which may be of key importance. While inflammation and proinflammatory gut microbiota are often associated with disease in adults, proinflammatory gut microbiota may be an essential aspect of immune system training in early life. It is interesting to speculate about some of our findings in this context. For example, species ofBifidobacterium are generally thought to promote health, particularly in infants. Consistent with many prior studies, we found that early abundance of OTUs ofBifidobacterium sp. and Bifidobacterium longum was associated with lower BMI. However, we found that Bifidobacterium bifidum at 10 days showed the opposite association with BMI. While the positive association of B. bifidum at 10 days with childhood BMI seen in our results could also be spurious, these findings are concerning because strains of this species are included in many prenatal and infant probiotics. One of the few prior studies that likewise examined gut microbiota at numerous early time points in life found that infants with later acquisition of high levels of Bifidobacterium and Collinsella had lower adiposity at 18 months of age. Thus, it is possible that the timing of colonization by Bifidobacterium has important consequences for later adiposity, or that there are important strain-level differences in the effects of Bifidobacterium in early life.” “Overall, our findings show a strong association between infant gut microbiota at age two and BMI at age 12 and show that the gut microbiota characteristics predictive of later BMI precede excessive weight gain, suggesting that the gut microbiota could have potential to help identify children at risk for obesity. We also found some support for the hypothesis that maternal Ow/Ob may influence some of the infant gut microbiota taxa that are associated with later BMI. Further studies of the specific bacteria highlighted in our results may also lead to greater understanding of the etiology of obesity.”

 Exosomes of pasteurized milk: potential pathogens of Western diseases. Journal of Translational Med 2019, PMID:30602375  DOI:10.1186/s12967-018-1760-8

“… epidemiological and translational evidence presented in this review indicates that continuous exposure of humans to exosomes of pasteurized [cows’]milk may confer a substantial risk for the development of chronic diseases of civilization including obesity, type 2 diabetes mellitus, osteoporosis, common cancers (prostate, breast, liver, B-cells) as well as Parkinson’s disease. Exosomes of pasteurized milk may represent new pathogens that should not reach the human food chain.” MM: important when cows’ milk is being pushed in pregnancy, especially in Asia. Heat-treatment is not all benign, and a sole diet of pasteurised human milk might also have risks. For more on exosomes: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453147/

WHO Guidance re marketing of complementary foods: https://www.who.int/nutrition/publications/infantfeeding/manual-ending-inappropriate-promotion-food/en/

WHO materials re complementary foods have been excellent, and support responsive feeding; they are readily available online. UNICEF UK also has some good resources. Remarkably good resources are available to download free at the UK’s First Steps Nutrition Trust. Sample booklet on display.  https://www.firststepsnutrition.org

WHO Europe re sugar in complementary foods: http://www.euro.who.int/en/media-centre/sections/press-releases/2019/whoeurope-studies-find-baby-foods-are-high-in-sugar-and-inappropriately-marketed-for-babies

Early-Life Exposure to Non-Nutritive Sweeteners and the Developmental Origins of Childhood Obesity: Global Evidence from Human and Rodent Studies,PMID:29439389; http://europepmc.org/articles/PMC5852770 doi10.3390/nu10020194 “There is an emerging body of evidence from human and animal studies suggesting that early-life exposure to NNS may have adverse effects on cardio-metabolic health and development..” “regular NNS intake during pregnancy may program an adverse metabolic profile in the developing fetus, leading to increased weight gain and adiposity after birth.” “Prenatal or early postnatal NNS exposure may also influence how the developing brain perceives sweet taste. While they have no nutritional impact, NNS trigger sweet taste receptors and routine exposure may alter thresholds for sweet taste perception, imparting a stronger preference for sweet foods later in life.”  “NNS have been shown to alter the gut microbiota in rodents, leading to impairments in glucose tolerance and the development of metabolic changes and obesity”  “no human or animal studies have evaluated early-life exposure to the increasingly popular plant-derived NNS, such as stevia,which are commonly perceived to be “healthier” because they are extracted from natural sources.” MM: Is use of these products, such as stevia, increasing in foods and formulas for pregnant and lactating women, due to the emphasis on weight control?Are they found in pregnancy formulas?Industry’s move to ‘clean-label’ needs to be known: informative labelling is decreasing.

ALLERGY  [= FOOD HYPERSENSITIVITY OF MANY KINDS]

Search in databases for anything on allergy by Prof Meghan Azad and the Canadian CHILD Study, and the Manitoba database; and keep up with the emerging stem cell story. Already there is talk of repair capability. https://www.youtube.com/watch?v=eL9dAGiCNLUhttps://www.youtube.com/watch?v=8-XSR9yDG_c

 Stem cells in human breast milk.Hum Cell2019 DOI: 10.1007/s13577-019-00251-7  PMID:30972555  “Breast-feeding is an indispensable post-parturition stage in the process of mammalian reproduction” “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.”  MM: And of course, in babies, though there’s no money in that. Free stem cell transplants with no side effects come from every mother to her child…

Breastmilk cell trafficking induces microchimerism-mediated immune system maturation in the infant. Pediatric Allergy and Immunology2018,  PMID:29197124 https://doi.org/10.1111/pai.12841

“Initiating breastfeeding within the first hour of life confers an important benefit in terms of child mortality and severe morbidity. Intestinal permeability to ingested macromolecules and immunoglobulins is limited to the first days of human life. These exchanges cease in the very early post-partum , but may increase beyond the neonatal period in response to local inflammation or introduction of a weaning food. From animal- and limited human-based observations, compelling evidence points out to breastmilk cells also trafficking from mother to infant mucosal tissues and participating to the maternal microchimerism. The precise nature of breastmilk cells that are involved is presently not known but likely includes progenitor/stem cells-representing up to 6% of breastmilk cells-with possible contribution of mature immune cells. Stem cell microchimerism may induce tolerance to non-inherited maternal antigens (NIMAs), breastfeeding generating regulatory T cells (Treg ) that suppress antimaternal immunity. Therefore, in complement to pregnancy-induced microchimerism, breastfeeding-induced microchimerism may be pivotal in infant immune development, intestinal tissue repair/growth and protection against infectious diseases. As a continuum of the gestational period, the neonatal gut may be considered as a temporary, but important developmental extension of the role played by the placenta during intrauterine life; breastmilk playing the role of maternal blood by delivering maternal soluble factors (macromolecules, Ig, cytokines) and immunologically active milk cells. A better understanding of breastfeeding-induced maternal microchimerism would provide further evidence in support of public health messages that reinforce the importance of early initiation of breastfeeding.” MM: truly exclusive from birth BF, that means..Infant feeding comparisons: a hazard to infant health?Auerbach KG, Renfrew MJ, Minchin M. J Hum Lact 1991, 7(2):63-68PMID:2036157Bad definitions have been key to protecting formula from critical scrutiny, and they continue in all studies but a very few. Mostly means at best, “nothing but breastmilk on the day of study recruitment” often 2-3 weeks after birth; rarely involves checking hospital records, and even they are unreliable: Danish study.  

WAO 2016 Allergy Guidelines World Allergy Organ J. 2016. doi:10.1186/s40413-016-0102-7suggests using prebiotic supplementation in not-exclusively breastfed infants and NOT using prebiotic supplementation in exclusively breastfed infants. MM: huge questions here, and this generation of babies are the guinea pigs. Since faecal studies began industry has attempted to make formula stools “closer to” breastmilk. They can achieve this by feeding mothers the organisms found in formulas, which is one reason for the new emphasis on pregnant women.

Use of partially hydrolysed formula in infancy and incidence of eczema, respiratory symptoms or food allergies in toddlers from the ELFE cohort.(PMID:31206800) https://onlinelibrary.wiley.com/doi/abs/10.1111/pai.13094 Re PHF and allergy risk… “In this nationwide study, pHF‐HA use was not associated with a lower risk of any of the studied outcomes. Quite the reverse, it was associated with a higher risk of wheezing and FA. This should be confirmed in further studies.”

Formula supplementation remains a risk for cow’s milk allergy in breast‐fed infants Pediatric Allergy and Immunology2018 DOI: https://doi.org/10.1111/pai.13108

“Formula supplementation was significant (OR 16.62, 95%C.I. 3.89 – 71.11), indicating that breast‐fed infants who were given formula supplements were 16 times more likely to exhibit CMPA than those who were exclusively bottle‐fed.”  45.8% breast‐fed infants (<24h) received supplemental formula.  “Breast fed babies are still being put at significantly increased risk of CMPA by receiving supplemental formula in the first 24 hours of life, despite the major predictors of supplementation being subjective and remediable in other ways. Mothers and health care providers should be better educated on the benefits of exclusive breast feeding and resourced adequately to avoid unnecessary formula supplementation to reduce risk of development of CMPA.” MM: not good enough just to tell women this. Give them strategies to make it harder for ignorant doctors to give supplements. In pregnancy, express colostrum or get donor milk in syringes, take in frozen; keep baby and MOTHER and partner skin to skin; educate partner about the need to protect mother and baby; make wishes known in writing and before birth; get help establishing BF; do not allow families to interfere. If mother was formula fed, work through this issue with grandmother and enlist her help. And work for societal change to enable breastfeeding.

Postnatal exposure to household disinfectants, infant gut microbiota and subsequent risk of overweight in children.CMAJ. 2018 .DOI: 10.1503/cmaj.170809PMID:3022444“Commonly found in infants with detected Lachnospiraceae, genus Ruminococcus became 1.6 times more likely to have higher abundance with frequent use of disinfectants in our study infants, in conjunction with lowered abundance of genus Haemophilus and Clostridium. This same compositional profile is typical of eczema in children. Antibacterial cleaning products have the capacity to change the environmental microbiome and alter risk for child overweight. Our study provides novel information regarding the impact of these products on infant gut microbial composition and outcomes of overweight in the same population.”

Use of partially hydrolysed formula in infancy and incidence of eczema, respiratory symptoms or food allergies in toddlers from the ELFE cohort “Among 11,720 infants, those who received only breast milk at 2 months were at lower risk of eczema at 1 year than those who received nHF …The use of pHF/HA, compared with nHF, at 2 months was related to higher risk of wheezing at 1 year in at-risk infants…and higher risk of FA at 2 years in both groups.” In this nationwide study, pHF/HA use…..was associated with a higher risk of wheezing and FA. This should be confirmed in further studies. https://onlinelibrary.wiley.com/doi/abs/10.1111/pai.13094

MM: Partially hydrolysed formulas (pHF or HA) [Comfort/Gentle etc] are often recommended in non-breastfed infants with familial history of allergy. Should they be? I don’t think so…They worked initially in the 1980s, in first generations exposed to them.  Don’t know if they’re better for the non-allergic (if you can find any child born these days without family allergy when well-questioned.) Many studies need to control for intergenerational formula exposures.

Allergenicity of refined vegetable oils. Food Chem Toxicol. 2000 https://www.ncbi.nlm.nih.gov/pubmed/10722892 “Several commercially important refined vegetable oils are derived from plants which are recognized as potent food allergens (e.g. peanut, soy). Full refining of oils results in the almost complete removal from oils of protein, which is responsible for allergic reactions. However, it is uncertain whether the minute amounts remaining could provoke allergic reactions in highly susceptible individuals. This has led to a vigorous debate about the safety of refined oils and specifically whether to label each oil individually because of the potential risk of allergenicity. Peanut oil has been the most thoroughly studied. It has been shown, in well-designed studies, that refined peanut oil can be safely consumed by the vast majority of peanut-allergic individuals, whereas unrefined oil can provoke reactions in some of the same individuals. However, some other studies report cases of allergic individuals reacting to oils, which are presumed to be refined. While it is likely that the discrepancy between these observations is due to differences in the processing of the oils, and possibly the protein content, this has not been formally demonstrated. Few data exist on the potential allergenicity of other edible vegetable oils; what data there are suggest that the major oils (soy, maize, sunflower, palm) do not provoke allergic reactions in susceptible individuals. Determining the content and immunoreactivity of the residual protein of refined oils is crucial to assessing the allergenic risk they present. Current methodology is inadequate and has not been validated for use with oils and aqueous extracts from oils.Little is known about the importance of different processing steps on allergenicity, although this information is crucial to risk assessment, particularly when considering process modifications. Available data suggest that the protein content of crude oils is of the order of 100-300 microg and that refining results in levels up to about 100-fold lower. The review concludes that peanut oil, and by extrapolation other edible vegetable oils, presents no risk of provoking allergic reactions in the overwhelming majority of susceptible people. However, there is a need to standardize and validate methodology for measuring the protein content and immunoreactivity of such so that they can be used to maintain process specifications. Thresholds of reactivity to allergens in man also need to be established in order to assess fully the risk from very small amounts. MM: allergy in infants is not only to bovine protein. Major allergens vary by country and relate to diet. Corn eg.

Microbes and formula preparation concerns. WHO guidance re formula preparation using hot water is completely ignored by formula companies as it is incompatible with their product (heat labile vitamins, live microbes). But many cans now recommend single serve makeup of feeds. Legal responsibility for harms is thus put on to those who advise batch preparation, or who do it out of convenience. There is no warning and parents reject a statement such as “powdered infant formula is never sterile.” Can labelling, is needed and could be achieved wherever there are consumer protection laws, by a campaign to educate parents about infant formula.

Quality of probiotic products for preterm infants: contamination and missing strains.Acta Paediatr 2019. PMID:31423636 DOI: DOI: 10.1111/apa.14976 Report of “..a safety issue concerning contamination by pathogenic bacteria and missing of labeled strains in a probiotic product widely used in neonatal care. We recommend all centers using probiotics in the care of vulnerable patients to consider product safety checks in addition to the quality reports of manufacturers.” MM: This will need to happen.  And add cost and/or cause harm. The use of fresh or heat treated donor milk is less expensive, and “refaunation” enables donor milk to become mother’s own.

An industry consultants’ report on probiotics and prebiotics, bugs and their foods https://pentec-consulting.eu/probiotics-and-prebiotics-in-infant-formula-regulatory-status-and-innovation/

“….regular milk, which is used in the manufacturing of infant formula (IF) and follow-on formulas (FOF), cannot shape infant immune systems as human milk does. For that purpose,probiotics and prebiotics have been added to IF and FOF for a long time to supply the lack of naturally present immunomodulators. Research and innovation in those products aim to mimic human milk’snatural content in nutrients, prebiotics and probiotics to provide non-breastfed infants the same health benefits.  Special remarks should be made on the development and introduction of synthetic human milk oligosaccharides in the market, which have played an invaluable role in the refinement of IF and FOF.”

“Surprisingly, despite the wide use of live microorganisms in infant formulas over the past decades, the use of probiotics is still not regulated by specific laws in the EU. Its use in IF and FOF is only supported by Article 5 to Directive 2006/141/EC, which states that other ingredients (in addition to the ones disclosed in the same law) may be added to IF if their safety and suitability for infants can be proven.

“In addition, Regulation (EC) No. 1333/2008 specifies that non-pathogenic L(+)-lactic acid producing cultures are allowed to be used in the manufacturing of acidified milks. Nevertheless, the addition of prebiotics, in the form of fructo-oligosaccharides and galacto-oligosaccharides, is explicitly permittedunder the same Directive. It is to be noted that Directive 2006/141/EC supposed a big step for the industry as it enabled health claims to be used in IF and FOF, while the old Directive 91/321/EC only allowed nutritional claims. The list of authorised nutrition and health claims in IF and FOF is disclosed in Annex IV to Directive 2006/141/EC. Nevertheless, no health claim in IF and FOF has been authorised so far, and only protein hydrolysates can bear a claim describing its role in reducing the risk of developing allergy to milk proteins.

The Panel concluded that there was no need to include probiotics in IF and FOF but considered that its consumption does not raise any health concern. Based on the same arguments, the Panel drew the same conclusion for non-digestible oligosaccharides. Considering that the effect of prebiotics is strongly linked to that of probiotics, the lack of health claims related to prebiotics is unsurprising.

Unfortunately, manufacturers will see their efforts [MM: to get more health claims allowed] thwarted after 22 February 2020(21 February 2021 for protein hydrolysates) when the old Directive 2006/141/EC will be repealed and replaced by Regulation (EC) No. 609/2013. After that date, health and nutrition claims will be forbidden on IF and FOF in accordance with Article 8 to Commission Delegated Regulation (EU) No. 2016/127 supplementing Regulation (EC) No. 609/2013 in an attempt to protect breastfeeding.  Unfortunately, this prohibition will limit the already restricted marketing strategies for IF and FOF.” MM: But not in the areas outside European regulation, like Asia, where health claims are rife. And not in the UK if Brexit goes ahead. And they’ve never been seriously limited by US authorities. Consumers wanting this protection under EU regulation should look to see where the formula is made, though there is no guarantee that exported formula will always meet home use standards.

Final Thoughts

Infant formula is the problem. Breastfeeding is the solution. Not the reverse, as currently in too many places. The best evidence for the necessity of breastfeeding is the reality of infant formula. Both cowardice and convention prevent health advocates from focussing on getting educated themselves, and educating society, about infant formula. I consider it a misreading of the Code, and a betrayal of its stated aims, to say that formula feeding should never be discussed with pregnant families. Properly done, it should increase the likelihood that they initiate breastfeeding, which in itself may be profoundly powerful; and I believe it will create a societal revolution, because parents do want the best for their children. Milk Matters provides much of the evidence you need, and my website and Facebook page and future publications will continue to address the new evidence as it arises. If you truly cannot afford to buy a copy, even of the e-books, but will undertake to read the whole book, contact me. Maureen Minchin

WHAT FORMULA?  A GUESSTIMATE for when it is needed…

  • First formula only, and only to 12 months maximum. Widen diet of EFF infant from 4 months onwards; by 12 months ideally on family diet plus water.
  • FOFs and GUMs not needed, CM products are fine as part of dietafter 6 months. [Full cream milk after 12 months, as part of diet, not more than 350-400mL of ANY milk product, as it decreases diet variety.]
  • Vary brands?No large single batch purchases.
  • ?Major manufacturer, preferably experienced food (not pharma) giant with serious investment in research, and products subject to EU regulation and inspection.
  • Protein: no more than 15g/L, not less than 11g/L; not casein dominant; possibly yes to whey-only + alpha-lactalbumin; no to soy protein; pea/rice/sheep/camel protein = first generation experiment to be recorded, expect reactions in siucceeding generations if not immediately. Partially hydrolysed protein won’t work for allergy prevention.
  • Fats: yes to DHA and ARA; yes to milk fat; take note of oil sources; not arachis/peanut; record corn, palm, etc. Milk fat globule membrane probably yes, but don’t expect much..
  • Carbohydrates: lactose definitely included, no to corn syrup or maltodextrins from wheat, no to fructose. Oligosaccharides see below.
  • Iron: not as much as 12mg/L (associated with deficits); not below 2mg/L; roughly similar amount of zinc, not less than 3:2 ratio
  • Bacteria: Lactobacilli and Bifidus strains possibly useful only for EFF babies; not for partly breastfed [and if ever wanted for BF babies, via mother’s milk]
  • Nucleotides: unnecessary, a marketing tool, irrelevant
  • FOS/GOS+ bacteria = first generation experiments; possibly better for the totally formula fed, but note sources, as possibly allergy will emerge in second generation. Fructose intolerance may increase.
  • ?A2 milk: possibly if protein levels OK; not if above 15g/l
  • ?Organic: possibly; depends on definitions; most major manufacturers monitor cow environments; additives are unlikely to be organic; check certification standards
  • ?Grass fed: most milk cows get some grass, all cows get supplements or milk production drops; most cows are indoors in winter – what does it mean? Avoid lot-feeds if possible.
  • ?country of origin: no way of assessing if this matters. All countries have different risks and regulations; Codex is a minimum Manufacturers have greater or less experience, older or newer factories: no way of knowing Mexico/Indonesia/Germany/France?
  • “Natural” – they’re all synthetic/industrial foods. Even a Nestle patent refers to them as synthetic infant nutritionals (SINS?! joke, they are necessary at present)

Formulas are NOT all the same, even if they have the same brand name

They are not all as good or bad as one another

They are not all highly regulated if that means regular independent inspection, enforcement.

They ARE the same, in that they fit within Standards whose ranges in recipes are written around existing products, and largely influenced by their producers;

They are the same, in that a variance of about 15% from what is stated on the can is considered almost inevitable, so that when accuracy matters, in VLBW eg, they should be analysed;

They are the same, in that we don’t know – though we could- which produces best outcomes for infants on any parameter. The one best for brain development may not be the least allergenic, eg.

Health authorities could do a lot better for formula fed babies. And paradoxically, if the truth was spoken plainly, that would help breastfeeding promotion.