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Quality and Safety Aspects of Infant Nutrition. Ann Nutr Metab

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Quality and Safety Aspects of Infant Nutrition. Ann Nutr Metab Ann Nutr Metab 2012;60:179–184 Published online: June 6, 2012 DOI: 10.1159/000338803 Quality and Safety Aspects of Infant Nutrition a b c Berthold Koletzko Raanan Shamir Margaret Ashwell on behalf of the Early Nutrition Academy (ENA) and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) a b Dr. von Hauner Children’s Hospital, University of Munich Medical Centre, Munich , Germany; Schneider Children’s c Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv , Israel; Ashwell Associates Ltd., Ashwell , UK Key Words preceded by a thorough science based review of suitability Food safety ؒ Infant formula ؒ Follow-on formula ؒ and safety by an independent authority. Food safety events -Complementary feeding ؒ Breast-feeding should be managed on an international basis. Global collab oration of food producers, food-safety authorities, paediatri- cians and scientists is needed to efficiently exchange infor- Abstract mation and to best protect public health. Quality and safety aspects of infant nutrition are of key im- Copyright © 2012 S. Karger AG, Basel portance for child health, but oftentimes they do not get much attention by health care professionals whose interest tends to focus on functional benefits of early nutrition. Un- The interest of pediatricians, other health care profes- balanced diets and harmful food components induce par- sionals, and the public in infant nutrition products is of- ticularly high risks for untoward effects in infants because of ten focused on possible functional effects, such as poten- their rapid growth, high nutrient needs, and their typical de- tial risk reduction of allergic disorders or the potential pendence on only one or few foods during the first months benefits for child development or long-term health [1, 2] . of life. The concepts, standards and practices that relate to In contrast, pediatricians and other health care profes- infant food quality and safety were discussed at a scientific sionals often assume quality and safety as a matter of workshop organized by the Child Health Foundation and the course and do not devote the same level of attention to Early Nutrition Academy jointly with the European Society these aspects. for Paediatric Gastroenterology, Hepatology and Nutrition, However, quality and safety issues are of key impor- and a summary is provided here. The participants reviewed tance for infant feeding and child health. Suitability and past and current issues on quality and safety, the role of dif- safety are fundamental regulatory requirements for al- ferent stakeholders, and recommendations to avert future lowing the marketing of infant food products [3] . These issues. It was concluded that a high level of quality and safe- aspects are important because infants carry particularly ty is currently achieved, but this is no reason for complacen- high risks for untoward effects of unbalanced diets or of cy. The food industry carries the primary responsibility for harmful food components. Why? Because they grow rap- the safety and suitability of their products, including the idly and have high nutrient needs, and because during the quality of composition, raw materials and production pro- first months after birth usually one sole milk source must cesses. Introduction of new or modified products should be meet all the dietary requirements. Further, immature and © 2012 S. Karger AG, Basel Prof. Berthold Koletzko 0250–6807/12/0603–0179$38.00/0 Dr. von Hauner Children’s Hospital, University of Munich Medical Centre Fax +41 61 306 12 34 Lindwurmstrasse 4 E-Mail [email protected] Accessible online at: DE–80337 Munich (Germany) www.karger.com www.karger.com/anm E-Mail office.koletzko @ med.uni-muenchen.de rapidly developing infants have a high susceptibility to The issue was the change in the formulation of two soy harmful effects from many exposures. infant formulae which were introduced in 1978 by a major Breast-feeding is regarded as the optimal form of nu- infant formula manufacturer in the USA, with a marked trition for human infants because of its numerous health reduction in the sodium chloride content. These chloride advantages, including, for example, prevention of infec- deficient formulations induced hypochloremic metabolic tious diseases, promotion of neurodevelopment, and re- alkalosis and growth faltering in the babies who received duced risk of later obesity, diabetes, and hypertension them, and they were later also found to be associated with [4–6] . Despite these recommendations, the vast majority adverse long-term effects on developmental outcomes and of infants worldwide receive some infant formula at some with behavioral problems [10–13] . The United States Con- time during their first year of life, whether as their sole gress reviewed the matter and determined that protection source of nutrition or in combination with human milk, of infants fed infant formulae needed to be improved by or homemade or commercial complementary foods. greater regulatory control over infant formula, which led Hence, the concepts, standards, and practices that relate to the US Infant Formula Act of 1980 (Pub. L 96–359). to the quality and safety of food products for infants are This act first established minimum nutrient requirements of great public health importance. for infant formulae, defined adulteration and quality con- A workshop was held in Sorrento, Italy, in May 2011, trol procedures, and specified inspection requirements as on behalf of the charitable Child Health Foundation, Mu- well as recall procedures [9] . nich (www.kindergesundheit.de) and the Early Nutrition The establishment of this and further national, region- Academy (www.early-nutrition.org), in collaboration al, and global standards and regulations on infant formu- with the European Society for Pediatric Gastroenterolo- lae and baby foods has contributed to the very high level gy, Hepatology and Nutrition (www.espghan.org) to re- of safety of such products that exists today. Compared to view and discuss some of the key questions in this area. the enormous number of infants fed such products on a They specifically addressed the following questions: daily basis, only a very small number of adverse events (1) What lessons have we learned from past issues of qual- has become known. ity and safety? However, in spite of established standards and regula- (2) What do we agree are the current issues for quality and tions, the occurrence of nutrient deficiency due to com- safety? positional errors can still occur. In 2003, a thiamine defi- (3) What do we predict might be future issues for quality cient soy protein-based infant formula led to severe thia- and safety and why? mine deficiency in recipient infants with lactic acidosis, (4) Which stakeholders should worry about current and encephalopathy, cardiomyopathy, and deaths [14, 15] , future quality and safety issues (manufacturers, gov- along with long-term neurologic problems in surviving ernment, health professionals, others)? Why are they children [16–18] . This tragedy apparently resulted from issues for them? an error of the manufacturer in designing the nutrient (5) What recommendations do we agree for these stake- composition of the formula [19, 20] , and it calls for the ap- holder groups to improve concerning any current is- plication of even more stringent quality control measures. sues and to avert any predicted future issues? Not only nutrient deficiency, but also too high nutrient This report summarizes some general issues addressed intakes may cause adverse effects. An excessive supply of by the workshop. It is complemented by a series of reports dietary components, and the supply of unnecessary com- published in this issue of the journal which provide sum- ponents, can put a burden on the infant’s metabolic and maries and key conclusions of presentations held at the other functions. Dietary components that are not utilized workshop. or stored by the body must be excreted as such or in the form of metabolites, in most cases as solutes with the urine. However, water available to form urine is limited, and in- Safety Issues: Nutrient Contents fants particularly during the first months of life have a lim- ited ability to concentrate urine. Therefore, the need to ex- Standards and regulations for infant formula and oth- crete any additional solutes can reduce the margin of safe- er infant foods aim at ensuring high levels of safety and ty, particularly if the infant is stressed by fever or diarrhea. are much more rigorous than regulations for other food An impressive example of untoward effects of a too products [3, 7–9]. In fact, it was a serious safety issue that high nutrient intake is the observation that an additional led to the adoption of the US Infant Formula Act in 1980. daily iron intake of 1 mg/kg from 6 to 9 months of age 180 Ann Nutr Metab 2012;60:179–184 Koletzko et al. induces significantly impaired length growth in iron suf- currence of invasive infections occurred after prolonged ficient infants [21, 22] . Therefore, it is important to define storage of reconstituted formula at warm temperatures not only adequate minimum but also maximum ingredi- which can lead to a marked increase in bacterial numbers ent contents in infant food products [8] . and hence reach an infective dose [41, 42] . Reij et al. [43] recently estimated the burden of disease of Cronobacter infections in infants to the Dutch population as 19–24 A d u l t e r a t i o n disability-adjusted life years (DALYs) per year, of which 95% are due to meningitis. Based on these estimates, Probably the largest infant food safety problem ever Cronobacter infections represent 0.5–2.4% of the total es- occurred in 2008 in China: infant formula was produced timated burden of foodborne infections and intoxica- from milk to which melamine had been added to sham a tions and would be responsible for 0.5–0.7% of the men- higher protein content, which caused urolithiasis and re- ingitis burden to the entire Dutch population.
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