Dia mundial de proteção ao aleitamento materno

Em alusão ao Dia Mundial de Proteção ao Aleitamento Materno (21 de maio), a OPAS/OMS em parceria com o Unicef e IBFAN, propõe um debate sobre o impacto da comercialização de substitutos do leite materno nas decisões sobre alimentação infantil e os avanços e desafios da implementação do Código Internacional sobre a Comercialização de Substitutos do Leite Materno nos países.

Protein Quality in Infant Formulas Marketed in Brazil: Assessments on Biodigestibility, Essential Amino Acid Content and Proteins of Biological Importance.

Infant formulas, designed to provide similar nutritional composition and performance to human milk, are recommended when breastfeeding is not enough to provide for the nutritional needs of children under 12 months of age. In this context, the present study aimed to assess the protein quality and essential amino acid content of both starting (phase 1) and follow-up (phase 2) formulas from different manufacturers. The chemical amino acid score and protein digestibility corrected by the amino acid score were calculated. The determined protein contents in most formulas were above the maximum limit recommended by FAO and WHO guidelines and at odds with the protein contents declared in the label. All infant formulas contained lactoferrin (0.06 to 0.44 g·100 g-1) and α-lactalbumin (0.02 to 1.34 g·100 g-1) below recommended concentrations, whereas ĸ-casein (8.28 to 12.91 g·100 g-1), α-casein (0.70 to 2.28 g·100 g-1) and ß-lactoglobulin (1.32 to 4.19 g·100 g-1) were detected above recommended concentrations. Essential amino acid quantification indicated that threonine, leucine and phenylalanine were the most abundant amino acids found in the investigated infant formulas. In conclusion, infant formulas are still unconforming to nutritional breast milk quality and must be improved in order to follow current global health authority guidelines.

Conduct and reporting of formula milk trials: systematic review.

OBJECTIVE: To systematically review the conduct and reporting of formula trials. DESIGN: Systematic review. DATA SOURCES: Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1 January 2006 to 31 December 2020. REVIEW METHODS: Intervention trials comparing at least two formula products in children less than three years of age were included, but not trials of human breast milk or fortifiers of breast milk. Data were extracted in duplicate and primary outcome data were synthesised for meta-analysis with a random effects model weighted by the inverse variance method. Risk of bias was evaluated with Cochrane risk of bias version 2.0, and risk of undermining breastfeeding was evaluated according to published consensus guidance. Primary outcomes of the trials included in the systematic review were identified from clinical trial registries, protocols, or trial publications. RESULTS: 22 201 titles were screened and 307 trials were identified that were published between 2006 and 2020, of which 73 (24%) trials in 13 197 children were prospectively registered. Another 111 unpublished but registered trials in 17 411 children were identified. Detailed analysis was undertaken for 125 trials (23 757 children) published since 2015. Seventeen (14%) of these recently published trials were conducted independently of formula companies, 26 (21%) were prospectively registered with a clear aim and primary outcome, and authors or sponsors shared prospective protocols for 11 (9%) trials. Risk of bias was low in five (4%) and high in 100 (80%) recently published trials, mainly because of inappropriate exclusions from analysis and selective reporting. For 68 recently published superiority trials, a pooled standardised mean difference of 0.51 (range -0.43 to 3.29) was calculated with an asymmetrical funnel plot (Egger's test P<0.001), which reduced to 0.19 after correction for asymmetry. Primary outcomes were reported by authors as favourable in 86 (69%) trials, and 115 (92%) abstract conclusions were favourable. One of 38 (3%) trials in partially breastfed infants reported adequate support for breastfeeding and 14 of 87 (16%) trials in non-breastfed infants confirmed the decision not to breastfeed was firmly established before enrolment in the trial. CONCLUSIONS: The results show that formula trials lack independence or transparency, and published outcomes are biased by selective reporting. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2018 CRD42018091928.

Rates and time trends in the consumption of breastmilk, formula, and animal milk by children younger than 2 years from 2000 to 2019: analysis of 113 countries.

BACKGROUND: Previous analyses of trends in feeding indicators of children younger than 2 years have been limited to low-income and middle-income countries. We aimed to assess time trends in the consumption of different types of milk (breastmilk, formula, and animal milk) by children younger than 2 years from 2000 to 2019 at a global level. METHODS: In this time-series analysis, we combined cross-sectional data from 487 nationally representative surveys from low-income and middle-income countries and information from high-income countries to estimate seven infant and young child feeding indicators in up to 113 countries. Multilevel linear models were used in pooled analyses to estimate annual changes in feeding practices from 2000 to 2019 for country income groups and world regions. FINDINGS: For the absolute average annual changes, we found significant gains in any breastfeeding at age 6 months in high-income countries (1·29 percentage points [PPs] per year [95% CI 1·12 to 1·45]; p<0·0001) and at age 1 year in high-income countries (1·14 PPs per year [0·99 to 1·28]; p<0·0001) and upper-middle-income countries (0·53 PPs per year [0·23 to 0·82]; p<0·0001). We also found a small reduction in low-income countries for any breastfeeding at age 6 months (-0·07 PPs per year [-0·11 to -0·03]; p<0·0001) and age 1 year (-0·13 PPs per year [-0·18 to -0·09]; p<0·0001). Data on exclusive breastfeeding and consumption of formula and animal milk were only available for low-income and middle-income countries, where exclusive breastfeeding in the first 6 months of life increased by 0·70 PPs per year (0·51-0·88; p<0·0001) to reach 48·6% (41·9-55·2) in 2019. Exclusive breastfeeding increased in all world regions except for the Middle East and north Africa. Formula consumption in the first 6 months of life increased in upper-middle-income countries and in east Asia and the Pacific, Latin America and the Caribbean, the Middle East and north Africa, and eastern Europe and central Asia, whereas the rates remained below 8% in sub-Saharan Africa and south Asia. Animal milk consumption by children younger than 6 months decreased significantly (-0·41 PPs per year [-0·51 to -0·31]; p<0·0001) in low-income and middle-income countries. INTERPRETATION: We found some increases in exclusive and any breastfeeding at age 6 months in various regions and income groups, while formula consumption increased in upper-middle-income countries. To achieve the global target of 70% exclusive breastfeeding by 2030, however, rates of improvement will need to be accelerated. FUNDING: Bill & Melinda Gates Foundation, through WHO.

Perspective: A Legal and Nutritional Perspective on the Introduction of Quinoa-Based Infant and Follow-on Formula in the EU.

Infants are vulnerable consumers and highly depend on dietary proteins for growth and development during their first months of life. Infant formula (IF) and follow-on formula (FOF) have been developed to meet these requirements, although few protein sources are currently allowed to be used. At the same time, allergies to these available protein sources are becoming more frequent. There is thus a need to explore alternative protein sources for infant nutrition. One alternative could be quinoa, which is a pseudocereal that is naturally free from gluten and has a high protein content and quality. This review assessed the composition, nutritional properties, and applicability of quinoa proteins for IF and FOF as well as the legal framework for their use in the European Union (EU). The protein quality of isolated quinoa proteins (IQPs) is relatively high compared with other plant-based proteins like rice. Besides, during the protein isolation process, unfavorable compounds are mostly removed, ensuring that the final product can comply with the maximum residue concentrations allowed. Overall, IF and FOF are strictly regulated under the Foods for Specific Groups (FSG) Regulation (EU) No 609/2013 and more research is needed before the introduction of IQP in such products is considered, but this review shows it has several promising features that warrant further investigation.

ARA or no ARA in infant formulae, that is the question.

Recently, the European Commission issued a Delegated Regulation updating the compositional and information requirements for infant and follow-on formulae that are to be applied at the latest in February 2021. This new regulation changes the status of docosahexaenoic acid (DHA) from an optional ingredient to a mandatory nutrient in these formulae at levels between 20 and 50mg/100kcal (0.5-1% of fatty acids). By contrast, arachidonic acid (ARA) becomes an optional nutrient. Following publication of the new regulation, global scientific experts have expressed concerns regarding the potential health risks of new infant formulae containing only DHA, especially at levels higher than those in breast milk and infant formulae marketed to date. Both DHA and ARA play a crucial role in infant development. First, breast milk, the gold standard for infant feeding, contains both DHA and ARA. Second, during development, the conversion of linoleic acid into ARA through desaturation steps is not sufficient to meet nutritional needs, especially in carriers of newly identified genetic variants in fatty acid desaturases, which weaken the biosynthetic production of ARA. Third, circulating levels of DHA and ARA in breastfed infants can only be matched with the addition of both fatty acids to formulae. And fourth, most studies performed to date have demonstrated that important physiological and developmental endpoints are sensitive to the ratio of dietary ARA:DHA. The precautionary principle applies when implementing the new EU regulation for infant and follow-on formulae. As a consequence, given the vulnerability of developing infants as well as the absence of conclusive evidence that formulae with at least 20mg DHA/100kcal, but no ARA, are safe and suitable to support the growth and development of infants similar to their breastfed peers, it remains necessary to still market formulas containing both ARA and DHA until proved otherwise.

Occurrence, sources, and pathways of chemical contaminants in infant formulas.

Infant formulas are manufactured products to meet specific nutritional requirements for infants. However, infant formulas can contain harmful substances, such as chemical contaminants and residues, normally due to possible contamination of the raw material or from the production chain. Some studies have demonstrated that veterinary drugs, pesticides, mycotoxins, heavy metals, packaging materials, within other chemicals are found in infant formulas from different sources of contamination. It is known that some of these substances can be hepatotoxic, carcinogenic, teratogenic, mutagenic, immunotoxic, contributing to antibiotic resistance, among other detrimental consequences for consumers' health. The purpose of this review is to assess the scientific evidence concerning the occurrence, sources, and pathways of contamination, as well as the detrimental impacts on infant health due to the possible presence of chemical contaminants and residues in infant formulas. Moreover, strategies to reduce the risk of contamination of infant formulas are presented to ensure the highest standards of quality of infant formulas. The entire infant formula manufacturing process should be monitored and controlled to minimize the risk of contamination during processing, storage, and distribution, besides ensuring the use of raw materials with as low as acceptable levels of harmful substances in order to assure that the final product shall comply with the maximum levels and maximum residue limits, when established, for residues and contaminants in the final product.

Microbiological Quality of Powdered Infant Formula in Latin America.

ABSTRACT: Cronobacter is a bacterial genus that includes seven species, and the species Cronobacter sakazakii is most related to meningitis and septicemia in infants associated with powdered infant formula (PIF). The objectives of this study were to evaluate the presence of C. sakazakii and to determine the microbiological quality of PIF for infant consumption. To do this, a total of 128 PIF samples were analyzed in four brands and countries (Chile, Mexico, Holland, and Brazil), considering three types of PIF: premature (PIF1), infant (PIF2), and follow-up (PIF3). Aerobic plate counts (APC) and Enterobacteriaceae (ENT) were assessed in accordance with Chilean official standards. The outer membrane protein A (ompA) gene was amplified to detect Cronobacter spp. and the fusA gene was amplified to identify C. sakazakii by using the PubMLST Web site and BLAST (NCBI). The antibiotic resistance profile was performed according to the Clinical and Laboratory Standards Institute standards. The pathogen was quantified by the most probable number (MPN). The results showed that APC median values for PIF1, PIF2, and PIF3 were 3.2, 4.9, and 4.8 log CFU g-1, respectively. The APC were higher in PIF2 (P < 0.01) from Holland (P < 0.01) in the commercial brand 4 (P < 0.01). The ENT median values in PIF1, PIF2, and PIF3 were 1.8, 1.5, and 1.7 log CFU g-1, respectively. Five strains of C. sakazakii and one strain of Cronobacter malonaticus were identified as having values between 0.023 and 2.3 MPN/g. All strains (100%) harbored the ompA, plasminogen activator (cpa), and hemolysin (hly) virulence genes. To conclude, C. sakazakii was found in four PIF samples from four Chilean products and one from Mexico, which is distributed throughout America. C. sakazakii strains exhibit virulence factors and resistance to ampicillin, thus posing a risk when PIFs are consumed by infants.

Serum 25-hydroxyvitamin D concentration in childhood and risk of islet autoimmunity and type 1 diabetes: the TRIGR nested case-control ancillary study.

AIMS/HYPOTHESIS: Our aim was to study the association between serum 25-hydroxyvitamin D (25OHD) concentration and islet autoimmunity and type 1 diabetes in children with an increased genetic risk of type 1 diabetes. METHODS: Serum samples for 25OHD measurements were obtained in the Trial to Reduce IDDM in the Genetically at Risk (TRIGR) ancillary study (Divia) from children in 15 countries. Case children (n = 244) were defined as having positivity for at least two out of four diabetes-associated autoantibodies measured at any one sample. For each case child, two control children were selected matched for country and date of birth (±1 year) (n = 488). Of the case children, 144 developed type 1 diabetes. Serum 25OHD was measured repeatedly in infancy and childhood and was compared according to age at the first seroconversion (at 6, 12 and 18 months prior to and at seroconversion) and calendar age (0, 6, 12 and 18 months). RESULTS: In children with islet autoimmunity, mean serum 25OHD concentration was lower 18 months prior to the age of first seroconversion of the case children compared with the control children (57.7 vs 64.8 nmol/l, p = 0.007). In children with type 1 diabetes (n = 144), mean serum 25OHD concentration was lower 18 months prior to the age of the first seroconversion (58.0 vs 65.0 nmol/l, p = 0.018) and at the calendar age of 12 months (70.1 vs 75.9 nmol/l, p = 0.031) than in their control counterparts. Analyses were adjusted for month of sample collection, human leucocyte antigen genotype, maternal type 1 diabetes and sex. CONCLUSIONS/INTERPRETATION: The results suggest that early postnatal vitamin D may confer protection against the development of type 1 diabetes. TRIAL REGISTRATION: ClinicalTrials.gov NCT00179777.

A Baby Formula Designed for Chinese Babies: Content Analysis of Milk Formula Advertisements on Chinese Parenting Apps.

BACKGROUND: China is the largest market for infant formula. With the increasing use of smartphones, apps have become the latest tool used to promote milk formula. Formula manufacturers and distributors both have seized the popularity of apps as an avenue for marketing. OBJECTIVE: This study aimed to identify and analyze milk formula ads featured on Chinese pregnancy and parenting apps, to build the first complete picture of app-based milk formula marketing techniques being used by milk formula brand variants on these apps, and to more fully understand the ad content that potentially undermines public health messaging about infant and young child feeding. METHODS: We searched for free-to-download Chinese parenting apps in the 360 App Store, the biggest Android app store in China. The final sample consisted of 353 unique formula ads from the 79 apps that met the inclusion criteria. We developed a content analysis coding tool for categorizing the marketing techniques used in ads, which included a total of 22 coding options developed across 4 categories: emotional imagery, marketing elements, claims, and advertising disclosure. RESULTS: The 353 milk formula ads were distributed across 31 companies, 44 brands, and 79 brand variants. Overall, 15 of 31 corporations were international with the remaining 16 being Chinese owned. An image of a natural pasture was the most commonly used emotional image among the brand variants (16/79). All variants included branding elements, and 75 variants linked directly to e-shops. Special price promotions were promoted by nearly half (n=39) of all variants. A total of 5 variants included a celebrity endorsement in their advertising. A total of 25 of the 79 variants made a product quality claim. Only 14 variants made a direct advertisement disclosure. CONCLUSIONS: The purpose of marketing messages is to widen the use of formula and normalize formula as an appropriate food for all infants and young children, rather than as a specialized food for those unable to breastfeed. Policy makers should take steps to establish an appropriate regulatory framework and provide detailed monitoring and enforcement to ensure that milk formula marketing practices do not undermine breastfeeding norms and behaviors.

Manganese levels in infant formula and young child nutritional beverages in the United States and France: Comparison to breast milk and regulations.

Exposure to high levels of manganese (Mn) in children has recently been associated with adverse neurodevelopmental effects. Current infant formula regulations for Mn content were set between 1981 (United States), 2006 (European Union, France), and 2007 (Codex Alimentarius) prior to the publication of much of the growing body of research on the developmental neurotoxicity of Mn. In this study, we sought to measure the concentrations of Mn in some infant formulas and young child nutritional beverages available on the United States (US) and French markets using ion beam analysis by particle induced X-ray emission (PIXE) spectrometry and then compare the analytical results to concentrations reported in the literature for breast milk and applicable infant formula regulations and guidelines. We were particularly interested in measuring Mn concentrations in product types for which there is very little data from previous surveys, especially soy-based, rice-based, goat-milk based, chocolate-flavored, and nutritional beverages for young children that are not regulated as infant or follow-on formulas (e.g. "toddler formulas" and "toddler powders"). We purchased 44 infant formulas and young child nutritional beverage products in the US and France with varying protein sources (cow-milk, goat-milk, soy, rice) labelled for birth to 3 years. We selected these samples using maximum variation sampling to explore market extremes to facilitate comparisons to regulatory limits. Since this sampling method is non-probabilistic, other inferences cannot be made beyond this set of samples to the overall markets. We used ion beam analysis to measure the concentrations of Mn in each product. The range of measured Mn concentrations in the products is 160-2,800 µg/L, substantially higher than the 3-6 µg/L mean Mn concentration reported in human breast milk. All products satisfied national and Codex Alimentarius Commission (CAC) international standards for minimum Mn content in infant formulas; however, 7/25 of the products purchased in the US exceeded the CAC Guidance Upper Level of 100 µg Mn/kcal for infant formula.

Is Donated Breast Milk Better Than Formula for Feeding Very Low Birth Weight Infants? A Systematic Review and Meta-Analysis.

BACKGROUND: The role of donated breast milk and formula feeding in very low birth weight infants (VLBWIs) remains unclear. OBJECTIVE: The objective for this study was to evaluate the efficacy and safety of breast milk and formula for feeding VLBWIs. METHODS: A comprehensive search of PubMed databases was conducted on November 30, 2018, to identify related randomized controlled trials (RCTs). Pooled odds ratio (OR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using either a fixed or random-effects model. RESULTS: Seven RCTs with a total of 876 infants were included. The formula showed more advantages in increasing infant weight (MD = -6.58, 95% CI: -11.19 to -1.98) and length (MD = -0.30, 95% CI: -0.41 to -0.20) than donated breast milk, but formula could also significantly increase the risks of necrotizing enterocolitis (OR = 0.33, 95% CI: 0.18 to 0.59) and length of hospital stay (MD = -3.78, 95% CI: -6.84 to -0.72) when compared with donated breast milk. No significant differences on the head circumference gain (MD = -0.16, 95% CI: -0.33 to 0.01), sepsis (OR = 1.21, 95% CI: 0.84 to 1.75), retinopathy of prematurity (OR = 1.22, 95% CI: 0.73 to 2.05) and mortality (OR = 0.84, 95% CI: 0.47 to 1.52) were found. LINKING EVIDENCE TO ACTION: The donated breast milk shows more advantages in reducing the incidence of NEC and length of hospital stay, but also more disadvantages in increasing the weight and length of VLBWIs and ELBWIs when compared with preterm formula feeding. Currently, there is no solid evidence demonstrating a significant advantage of donated breast milk over formula in the feeding of VLBWIs. Larger-scale RCTs with rigorous designs are needed to elucidate the feeding plans of VLBWIs.

Mothers living with HIV: replacing breastfeeding by infant formula / Madres viviendo con VIH: la sustitución de la lactancia por una fórmula láctea infantil / Mães vivendo com HIV: a substituição do aleitamento por fórmula láctea infantil

ABSTRACT Objective: To explore factors that interact and shape the meaning and experience of mothers of HIV-exposed children in relation to replacing breastfeeding by infant formula. Method: A qualitative study was carried out with 23 mothers living with HIV, whose children were up to 18 months of age and under follow-up in a specialized care service. Symbolic Interactionism, semi-structured interviews and content analysis were adopted as theoretical framework. Results: The social symbols of breastfeeding, the (un)availability of the milk formula and the (lack of)support of health professionals influenced the mothers' experience with formula feeding. Social, cultural and economic constraints have proved capable of undermining the conditions necessary for the replacement of breastfeeding. Final considerations: The availability of infant formula, access to lactation inhibitor and quality of health services still represent challenges to eradicate new HIV infections in children.

RESUMEN Objetivo: Explorar los factores que interactúan y moldean el significado y la experiencia de madres de niños expuestos al VIH en relación a la sustitución de la lactancia por una fórmula láctea infantil. Método: Estudio cualitativo, con 23 madres viviendo con VIH, cuyos hijos tenían hasta 18 meses de edad y estaban bajo seguimiento en servicio de asistencia especializada. Se adoptaron el Interaccionismo Simbólico como referencial teórico, entrevistas semiestructuradas y el análisis de contenido. Resultados: Los símbolos sociales de la lactancia, la (in) disponibilidad de la fórmula láctea y el (des) apoyo de los profesionales de la salud influenciaron a la experiencia de las madres con la alimentación por una fórmula láctea. Los cercos sociales, culturales y económicos se mostraron capaces de perjudicar las condiciones necesarias para la sustitución de la lactancia materna. Consideraciones finales: La disponibilidad de la fórmula láctea infantil, el acceso al inhibidor de la lactancia y la calidad de los servicios de salud todavía representan desafíos para eliminar nuevas infecciones por el VIH en niños.

RESUMO Objetivo: Explorar os fatores que interagem e moldam o significado e a experiência de mães de crianças expostas ao HIV em relação à substituição do aleitamento por fórmula láctea infantil. Método: Estudo qualitativo, com 23 mães vivendo com HIV, cujos filhos tinham até 18 meses de idade e estavam sob acompanhamento em serviço de assistência especializado. Foram adotados o Interacionismo Simbólico como referencial teórico, entrevistas semiestruturadas e análise de conteúdo. Resultados: Os símbolos sociais da amamentação, a (in)disponibilidade da fórmula láctea e o (des)apoio dos profissionais de saúde influenciaram a experiência das mães com a alimentação por fórmula láctea. Cerceamentos sociais, culturais e econômicos mostraram-se capazes de prejudicar as condições necessárias para a substituição do aleitamento materno. Considerações finais: A disponibilidade da fórmula láctea infantil, o acesso ao inibidor de lactação e a qualidade dos serviços de saúde ainda representam desafios para eliminar novas infecções pelo HIV em crianças.

Mothers living with HIV: replacing breastfeeding by infant formula.

OBJECTIVE: To explore factors that interact and shape the meaning and experience of mothers of HIV-exposed children in relation to replacing breastfeeding by infant formula. METHOD: A qualitative study was carried out with 23 mothers living with HIV, whose children were up to 18 months of age and under follow-up in a specialized care service. Symbolic Interactionism, semi-structured interviews and content analysis were adopted as theoretical framework. RESULTS: The social symbols of breastfeeding, the (un)availability of the milk formula and the (lack of)support of health professionals influenced the mothers' experience with formula feeding. Social, cultural and economic constraints have proved capable of undermining the conditions necessary for the replacement of breastfeeding. FINAL CONSIDERATIONS: The availability of infant formula, access to lactation inhibitor and quality of health services still represent challenges to eradicate new HIV infections in children.