CITATION: Labuschagne, I., Van Niekerk, E. & Lombard, M. J. 2013. Acidified infant formula explained. South African Family Practice, 55(3):354-356.The original publication is available at http://www.safpj.co.zaThe development of effective methods to prevent acute gastroenteritis is an important goal for infant health. Exclusive breastfeeding and postponement of complementary foods until the age of six months is recommended for healthy infants. However, at times, infant formula is required. Various types are commercially available. Acidified cow’s milk formula has been found to prevent the growth of pathogenic bacteria and concurring diarrhoeal disease.http://www.safpj.co.za/index.php/safpj/article/view/3729Publisher's versio

Labuschagne, Irene

Lombard, Martani J.

Van Niekerk, Evette

Stellenbosch University SUNScholar Repository

Review Article: Acidified infant formula explained354 Vol 55 No 3S Afr Fam Pract 2013IntroductionDiarrhoea remains one of the leading causes of mortality in infants in developing countries. Two major contributing factors of infant diarrhoea are poor hygienic conditions and contamination of infant food with bacterial pathogens (Escherichia coli and Salmonella) viruses (rotaviruses) and parasites (Cryptospridium).1 Breast milk remains the best source of nourishment for infants, and all mothers should be encouraged to breastfeed. 2,3 Breastfeeding reduces exposure to these pathogens and also supplies the infant with protective antibodies against food-borne pathogens, resulting in a decreased incidence of diarrhoea in breastfed children.1 The development of effective methods to prevent acute gastroenteritis in infants remains a central objective for infant health. Breastfeeding is associated with a decreased incidence of gastrointestinal infection, possibly because it promotes the growth of bifidobacteria in the intestinal tract, whereby the creation of an acidic environment is inhospitable to infectious organisms.4 Despite the numerous benefits of breastfeeding, it is not always an option or possible, as many women are unable to, or choose not to, breastfeed.5,6 A wide range of infant formula is commercially available, including acidified infant formula. Research indicates that intestinal infection is reduced in infants who receive biologically acidified infant formula.7,8Acidification of infant formulaAcidification of infant formula is acquired by one of two methods. The formula can either be chemically acidified through the addition of L-(+)lactic acid, or biologically acidified through fermentation, which transforms lactose into lactic acid. Chemically acidified formula appears to provide the same protection as that that is acidified through fermentation. In addition, attempts to modulate the microbiota toward increasing bifidobacteria counts have been achieved by the addition of living bifidobacteria (probiotics) or bifidogenic factors (prebiotics) to infant formula. Probiotics have been shown to be effective in the prevention and treatment of diarrhoea in infants.9 Figure 1 distinguishes between the different methods of acidification of infant for mula.Fermented milk products may induce a variety of gastrointestinal, immunological and other effects in the recipient organism. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition defines fermented formula as infant and follow-on formula that has been fermented with lactic acid-producing bacteria during the production process, but does not contain significant amounts of viable bacteria in the final product because of inactivation of the fermenting bacteria by heat or other means. This may include homogenisation, pasteurisation, sterilisation and/or spray-drying. The Commission of the European Communities directive on infant formula and follow-on formula permits the addition of live bacteria to infant and/or follow-on formula for the purpose of acidifying the formula. Fermented infant formula without live bacteria is usually not considered to be a probiotic product, based on the widely accepted definition of probiotics as “live microbial food ingredients that are beneficial to health”.10However, the scientific basis of this definition has been questioned because some probiotic effects were reported to be achievable by nonviable bacteria, and even by isolated bacterial DNA. Therefore, fermented formula without live Acidified infant formula explainedLabuschagne IL, BSc Dietetics, Principal Dietitianvan Niekerk E, M Dietetics, Lecturer; Lombard MJ, PhD, NICUS Manager, Registered Dietitian Nutrition Information Centre, Stellenbosch UniversityCorrespondence to: Martani Lombard, e-mail: nicus@sun.ac.zaKeywords: infant formula, acidified infant formula, fermented, probioticsAbstractThe development of effective methods to prevent acute gastroenteritis is an important goal for infant health. Exclusive breastfeeding and postponement of complementary foods until the age of six months is recommended for healthy infants. However, at times, infant formula is required. Various types are commercially available. Acidified cow’s milk formula has been found to prevent the growth of pathogenic bacteria and concurring diarrhoeal disease.  Peer reviewed. (Submitted: 2013-01-21. Accepted: 2013-00-00.) © Medpharm S Afr Fam Pract 2012;55(3):354-356Review Article: Acidified infant formula explained355 Vol 55 No 3S Afr Fam Pract 2013bacteria may be considered to have probiotic effects if the bacterial components or bacterial metabolites in these products have been revealed to have beneficial effects on infant health.10Acidified cow’s milk formula is acidified infant formula that inhibits the growth of harmful bacteria in the prepared feed. Therefore, acidified milk provides some advantage over non-acidified formula in children with mild digestive problems (or in situation in which there are less than ideal hygienic circumstances) through the prevention of rapid microbial proliferation achieved by acidification.11,12Furthermore, attempts to modulate the microbiota in formula-fed infants towards increased bifidobacteria counts have been achieved by adding living bifidobacteria.9The ESPGHAN Committee on Nutrition systematically reviews published data on the effects of fermented infant formula without live bacteria. The conclusion was that the available data are limited and do not allow firm conclusions to be drawn on the efficacy of fermented infant formula in combatting the severity of infectious diarrhoea in infants. The committee recommends that the effects of fermented infant formula on infectious diarrhoea and other relevant outcomes should be assessed in further randomised controlled trials in accordance with current scientific standards.10Acidified formula with added probiotic agentsExclusively breastfed infants have higher numbers of bifidobacteria and lower numbers of E. coli bacteria, while formula-fed infants harbour equal amounts of these different types of intestinal flora.13-16  The results of published randomised controlled trials have indicated that there is modest benefit to be gained from giving probiotics to prevent acute gastrointestinal tract infections in healthy infants and children. Rotavirus was the most common cause of acute diarrhoea in randomised controlled trials.17 The strains of probiotics used included Lactobacillus rhamnosus GG, Streptococcus thermophilus, L. casei, Bifidobacterium lactis or L. reuteri. These may be mixed with milk or infant formula, or given as an oral supplement. Chouraqui et al conducted a multicentre, double-blind, controlled study to evaluate the efficacy of a milk formula supplemented with viable B. lactis strain BB-12 in the prevention of acute diarrhoea in infants younger than eight months living in residential nurseries or foster care centres. They found that the prophylactic use of an acidified formula with low casein and phosphate, a high lactose content and living B. lactis BB-12 had a protective impact on acute gastroenteritis and nosocomial infections in these infants. The supplemented formula was biologically acidified by fermentation using a mixture of L-(+) lactic-acid-producing bacteria, i.e. S. thermophilus and L. helveticus.6 Velaphi et al further reported that infants receiving acidified formula had similar growth patterns to those in infants fed a standard whey formula, irrespective of the method of acidification. However, the addition of B. lactis to acidified formula resulted in greater weight gain, compared to that with standard formula.9Available formula in South AfricaNestlé Nan Pelargon and Aspen Melegi is chemically acidified formula which is commercially available in South Africa. Nan Pelargon has a whey to casein ratio of 50:50 and is intended from birth onwards. Aspen Melegi 1 is a starter formula with a whey to casein protein ratio of 60:40, indicated for newborn babies who are not being breastfed. Melegi 2 is indicated for babies from 6-12 months as a follow-up formula and is formulated to complement the infant’s weaning diet from six months, while Melegi 3 is a milk-based, growing-up nutritional supplement for 1- to 3-year-old active toddlers and children who need extra energy.12Acidified infant formulaBiological acidification (fermented)Chemical acidificationWith added probioticsWithout added probioticsFigure 1: Acidification of infant formulaReview Article: Acidified infant formula explained356 Vol 55 No 3S Afr Fam Pract 2013ConclusionAcidified infant formula shows the potential to inhibit the growth of harmful bacteria in the prepared feed. Breastfeeding should be encouraged in communities with poor sanitation, an inadequate safe water supply and high rates of infantile diarrhoea. If breastfeeding, heat-treated breast milk or donor breast milk is not possible, so acidified formula should be recommended, based on the available limited data. The published data on the effects of acidified and fermented infant formula without live bacteria are limited and do not allow firm conclusions to be made, yet they are promising, with no reported safety effects.Conflict of interestThe authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this paper.References1. Joosten HMLJ, Lardeau A. Enhanced microbiological safety of acidified infant formulas tested in vitro. SAJCN. 2004;17(3):87-92.2. O’Connor NR. Infant formula. Am Fam Physician. 2009;79(7):565-570. 3. Koletzko B, Baker S, Cleghorn G, et al. Global standard for the composition of infant formula: recommendations of an ESPGHAN coordinated international expert group. J Pediatr Gastroenterol Nutr. 2005;41(5):584-599. 4. Le Huerou-Luron I, Blat S, Boudry G. Breast- vs. formula-feeding: impacts on the digestive tract and immediate and long-term health effects. Nutr Res Rev. 2010;23(1):23-36.5. Hudara S, Mimouni F, Rachman Y, et al. Retrospective cohort study of a new infant formula during the first 6 months of life: reflections on growth curves, human milk and formula feeding. Isr Med Assoc J. 2010;12(11):676-680. 6. Chouraqui JP, Van Egroo L, Fichot M. Acidified milk formula supplemented with Bifidobacterium lactis: impact on infant diarrhea in residential care settings. J Pediatr Gastroenterol Nutr. 2004;38(3):288-292.7. Cooper PA, Bolton KD, Mokhachane M, et al. Growth of infants born to HIV-positive mothers fed a whey-adapted acidified starter formula with prebiotics and nucleotides.  S Afr J Clin Nutr.  2010;23(2):90-95. 8. Brunsor O, Araya M, Espinoza J, et al. Effect of an acidified milk on diarrhea and the carrier state in infants in low socio-economic stratum. Acta Paed Scand. 1989;78(2):259-264.9. Velaphi SC, Cooper PA, Bolton KD, et al. Growth and metabolism of infants born to women infected with human immunodeficiency virus and fed acidified whey-adapted starter formulas. Nutrition.  2008;24(3):203-211.10. Agostoni C, Goulet O, Kolacek Z, et al.  Medical position paper: fermented infant formulae without live bacteria. J Pediatr Gastroenterol Nutr. 2007;44(3):392-397.11. Joosten HMLJ, Lardeau A. Enhanced microbiological safety of acidified infant formulas tested in vitro. SAJCN. 2004;17(3):87-92.12. Johnston L. Infant formula explained. S Afr Fam Pract. 2011;53(5):23-26.13. Veereman-Wauters G. Application of prebiotics in infant foods. Br J Nutr. 2005;93(Suppl 1):S57-S60.14. Rao S, Srinivasjois R, Patole S. Prebiotic supplementation in full-term neonates: a systematic review of randomized controlled trials. Arch Pediatr Adolesc Med. 2009;163(8):755-764.15. Saavedra JM, Abi-Hanna A, Moore N, Yolken RH. Long-term consumption of infant formulas containing live probiotic bacteria: tolerance and safety. Am J Clin Nutr. 2004;79(2):261-267.16. Arslanoglu S, Moro GE, Boehm G. Early supplementation of prebiotic oligosaccharides protects formula-fed infants against infections during the first 6 months of life. J Nutr. 2007;137(11):2420-2424.17. Thomas DW, Greer FR, American Academy of Pediatrics Committee on Nutrition, et al. Probiotics and prebiotics in pediatrics. Pediatrics. 2010;126(6):1217-1231.

Acidified infant formula explained

The development of effective methods to prevent acute gastroenteritis is an important goal for infant health. Exclusive breastfeeding and postponement of complementary foods until the age of six months is recommended for  healthy infants. However, at times, infant formula is required. Various types are commercially available. Acidified cow’s milk formula has been found to prevent the growth of pathogenic bacteria and concurring diarrhoeal disease

Acidified infant formula explained

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