Faculty Bibliography

OBJECTIVES/OBJECTIVE:An acceptable alternative to human milk is US Food and Drug Administration (US FDA)-registered infant formula, which must meet the requirements of the US FDA Infant Formula Act. Human milk contains lactose, but some infant formulas may contain alternative carbohydrate sources such as corn syrup solids, maltodextrin, and sucrose. Recent research shows that infant-formula made with corn syrup solids may be associated with increased obesity risk in the first 5 years of life. A previous study found that of all formulas purchased, 59.0% were lactose-reduced. More US infants consume infant formula with nonlactose carbohydrates more frequently than is medically necessary. The purpose of this study is to use National Health and Nutrition Examination Survey (NHANES) data to describe the type and prevalence of nonlactose carbohydrates consumed in infant formula. METHODS:NHANES data from 1999 to 2020 was used to perform cross-sectional analyses and analyses of comparison of prevalence over time on consumption of nonlactose carbohydrate sources in infant formulas. RESULTS:We identified 3709 unique infant IDs associated with 36,084 feeding sessions. More than half of the feeding sessions involved a formula with at least one nonlactose carbohydrate. Feeding sessions involving a formula with at least one nonlactose carbohydrate increased by 163% from 1999-2004 to 2017-2020; formulas containing single or multiple nonlactose carbohydrate types account for the increase in prevalence. CONCLUSIONS:This study highlights an increase in the consumption of infant formula containing a nonlactose carbohydrate. More studies are needed to understand the short- and long-term effects of early exposure to these carbohydrates.

UNLABELLED:In May of 2022, millions of U.S. parents encountered uncertainty in safely feeding their infants due to the infant formula shortage. METHODS:An anonymous, electronic, cross-sectional, retrospective survey was used. RESULTS:< 0.05). Infants relying on specialty formulas experienced at least one undesirable outcome compared with non-specialty users. Parents used social media, relatives/friends and healthcare providers for support during the shortage, but their helpfulness scores were suboptimal. Parents reported the need for greater infant formula availability, free prenatal lactation education and postpartum lactation support. CONCLUSIONS:Government, regulatory and healthcare policy oversight are needed to protect the infant feeding system, including more commercially available products, access to banked donor milk and lactation support.

OBJECTIVE:ESPGHAN and the AAP state that young child formula (YCF) is not considered necessary for healthy children. Despite these recommendations, YCF accounts for approximately 13% of overall formula sales. Five percent of infants less than 1 year of age in the US are being fed YCF. The purpose of this study is to identify the most Internet recommended and encountered YCF in the US and determine if they meet nutritional recommendations for use in children 0-3 years. STUDY DESIGN/METHODS:We used the search terms "toddler formula", "toddler milk", "follow-up formula" or "young child formula" in Google and DuckDuckGo to identify the most like encountered or recommended YCF on the Internet. We compared their labeled nutrients to FDA IFA and international nutrient recommendations, given the absence of US nutrient requirements for YCF recommendations, for children 12-36 months. RESULTS:Twenty-nine YCF were reviewed. On average, YCF did not meet nutrient recommendations for infants and toddlers with 2.17 and 4.6 ingredients not meeting formula recommendations for younger and older infants, respectively, and between 3-4 ingredients for 12-36 months. CONCLUSION/CONCLUSIONS:Nutrition content of YCF are variable and do not meet FDA IFA requirements or YCF International recommendations. Increased US regulation is needed for YCF. It is important for health care providers to ask patients what they are feeding their infants and toddlers so they can educate parents on potential nutritional safety concerns.

OBJECTIVE:The AAP and NASPGHAN recommend either exclusively breastfeeding for at least 6 months or an FDA-reviewed infant formula or donor breast milk from an established milk bank as alternatives. The purpose of this study was to establish the prevalence of contemporary infant feeding practices such as informal human milk sharing, imported European infant formula, toddler formula and homemade formula and gain insight into the parental reasoning for their choices. STUDY DESIGN/METHODS:An anonymous, cross-sectional, voluntary electronic survey was sent to active prescribers to a Yumi (a baby subscription food company) list server in April and May, 2021. Basic demographic, utilization of infant feeding practices and general feeding practices were collected. RESULTS:Of 2,315 respondents, at least 18% of the families were following at least one contemporary feeding practice. 36% of parents using donor breast milk obtained it from unregulated sources, 14% of the respondents were using European infant formula, 5% were using toddler formula for their infants, and 2% were making home-made infant formula. CONCLUSION/CONCLUSIONS:The AAP has clear guidelines on infant nutrition and breastfeeding and when not possible, FDA reviewed infant formula or donor breast milk from an established milk bank as alternatives. Yet, our study found that at least 18% of the families across the US were following at least one contemporary feeding practice with possible nutritional and safety concerns. It is important for pediatric gastroenterologists and dieticians to ask their patients how they are feeding their infants and be aware of these feeding practices that may pose significant health risks.

Background: Nutrition during the first 1000 days of life has been shown to play a critical role in a child's health and development. Though the American Academy of Pediatrics (AAP) has recommended against the informal sharing of breast milk, young child formulas (YCF) for infants, imported European infant formulas (EIF) and homemade infant formulas (HIF), little is currently known about the US prevalence of these trends. One study of 499 postpartum women demonstrated that 4% had shared milk with either a family or friend, but it is unclear the number of infants using donor breast milk (

In 2018, the American Academy of Pediatrics warned consumers over the increasing use of imported infant formulas. The purpose of this study was to assess the usage of imported European infant formula among parents in a large urban private practice. An anonymous survey was distributed at well-child appointments to a convenience sample of parents at an urban private pediatric practice from November 2017 to March 2018. Of the 750 eligible respondents, 552 (74%) completed the survey. Of the parents using formula, 20% were using imported European infant formulas. The most commonly used formula was Holle (33%), and 72% were acquired from web-based third-party vendors. Parents chose to use these formulas because they believed that European formulas contained better ingredients. Only 8% of parents received information about European infant formula from their pediatricians. Pediatricians need to be aware of these formulas and their risks to educate families on the use and safety of these formulas.

OBJECTIVE:Infant formula in the United States is highly regulated. The AAP has reported concerns over the use of non-FDA registered imported infant formulas. The purpose of this study is to identify Internet purchased and recommended imported European infant formulas and compare them to FDA labeling and nutrient requirements. STUDY DESIGN/METHODS:We searched "European infant formulas" in Google and DuckDuckGo to identify vendors of European formulas and blogs discussing these formulas to determine the most frequently purchased and recommended brands. We then compared the identified European formulas' label and listed nutrients to FDA labeling and nutrient requirements. RESULTS:Thirteen of eighteen vendors responded to our inquiry of their top selling formula and 17 blogs were reviewed. Sixteen formulas were identified. None met all FDA label requirements. Listed nutrients fell within FDA requirements in 15 of 16 formulas. CONCLUSION/CONCLUSIONS:Non- FDA registered imported European formulas do not meet all FDA labeling requirements. Although linoleic acid, which was not listed on all of the European formulas, could not be evaluated, all formulas except one met the remaining FDA nutrient requirements. These European infant formulas are being imported into the US via third party vendors and are not FDA regulated, limiting the notable consumer protections set by the FDA that ensure infant formula safety. Pediatric gastroenterologists and health care providers need to understand the composition, labelling and lack of FDA regulation and safety concerns of these formulas in order to better counsel parents.

Immune thrombocytopenic purpura (ITP) is characterized by decreased platelet numbers secondary to platelet destruction and reduced platelet production. Even if the ITP persists, it typically responds to 'ITP-specific' therapies, such as intravenous immunoglobulin, steroids, intravenous anti-D, and splenectomy. Several reports, including our previous study, have implicated cytomegalovirus (CMV) in the pathogenesis of infrequent cases of ITP that were not severe in nature. A recent study from China suggested that CMV is the aetiology of some cases of acute ITP of childhood and may require different treatment. We report two adult and two paediatric patients with refractory, severe, symptomatic thrombocytopenia, who were diagnosed with ITP and found to have active CMV infection. Their presentations included fever, transaminitis, neutropenia, and atypical lymphocytosis, but in particular, treatment-refractory, severe ITP. Treatment with steroids appeared to worsen the CMV-ITP. All four cases showed improvement in platelet counts within two weeks of starting ganciclovir and cytogam and tapering steroids. Based on the four patients described here, we believe that, in certain cases, CMV infection will result in symptomatic, severe, refractory ITP, which may be indistinguishable from typical ITP. Eradication of CMV with antiviral therapy improved the ITP in these cases.