Peptidomic profile of human milk as influenced by fortification with different protein sources: An in vitro dynamic digestion simulation.

Fortification of human milk (HM) is often necessary to meet the nutritional requirements of preterm infants. The present experiment aimed to establish whether the supplementation of HM with either an experimental donkey milk-derived fortifier containing whole donkey milk proteins, or with a commercial bovine milk-derived fortifier containing hydrolyzed bovine whey proteins, affects peptide release differently during digestion. The experiment was conducted using an in vitro dynamic system designed to simulate the preterm infant's digestion followed by digesta analysis by means of LC-MS-MS. The different fortifiers did not appear to influence the cumulative intensity of HM peptides. Fortification had a differential impact on the release of either donkey or bovine bioactive peptides. Donkey milk peptides showed antioxidant/ACE inhibitory activities, while bovine peptides showed opioid, dipeptil- and propyl endo- peptidase inhibitory and antimicrobial activity. A slight delay in peptide release from human lactoferrin and α-lactalbumin was observed when HM was supplemented with donkey milk-derived fortifier.

Comparative proteomic analysis of donor human milk treated by high-pressure processing or Holder pasteurization on undigested proteins across dynamic simulated preterm infant digestion.

High-pressure processing (HPP) of donor human milk (DM) minimally impacts the concentration and bioactivity of some important bioactive proteins including lactoferrin, and bile salt-stimulated lipase (BSSL) compared to Holder pasteurization (HoP), yet the impact of HPP and subsequent digestion on the full array of proteins detectable by proteomics remains unclear. We investigated how HPP impacts undigested proteins in DM post-processing and across digestion by proteomic analysis. Each pool of milk (n = 3) remained raw, or was treated by HPP (500 MPa, 10 min) or HoP (62.5 °C, 30 min), and underwent dynamic in vitro digestion simulating the preterm infant. In the meal, major proteins were minimally changed post-processing. HPP-treated milk proteins better resisted proximal digestion (except for immunoglobulins, jejunum 180 min) and the extent of undigested proteins after gastric digestion of major proteins in HPP-treated milk was more similar to raw (e.g., BSSL, lactoferrin, macrophage-receptor-1, CD14, complement-c3/c4, xanthine dehydrogenase) than HoP.

Donor human milk practice in Indonesia: a media content analysis.

Introduction: Donor human milk (DHM) is recommended as the second-best alternative form of supplementation when a mother is unable to breastfeed directly. However, little is known about the experience of mothers and families in the communities regarding accessing and donating expressed breastmilk in Indonesia. This study aimed to identify the experience related to donor human milk in the society in Indonesia. Method: A search was conducted through six main online news portals. The keywords used included "donor human milk," "expressed breastmilk," and "wet nursing" in the Indonesian language, Bahasa Indonesia. A total of 107 articles were found, but only 20 articles were included for analysis using a qualitative media content analysis approach. Results: In the study, the following five themes were identified: (1) the whys and wherefores of donor human milk, (2) national and religious-based regulations, (3) recommendations from authorized organizations, healthcare professionals, and Islamic scholars, (4) the negative impact from the lack of national regulations, and (5) contradictory feelings among mothers. Conclusion: With the lack of detailed information on how to access or donate expressed human milk and the absence of a human milk bank in place, informal human milk sharing is inevitably occurring in the community. This has also raised concerns among authorized organizations, healthcare professionals, and Islamic scholars. Consequently, mothers, both donors and recipients, experienced negative impacts, which included contradictory feelings. Engaging with Islamic scholars and healthcare professionals to develop clear guidelines and regulations to enable mothers' and families' access and/or make contributions to DHM in a safe and accountable way is critical to prevent further problems from occurring in Indonesian society.

Maternal oral probiotic use is associated with decreased breastmilk inflammatory markers, infant fecal microbiome variation, and altered recognition memory responses in infants-a pilot observational study.

Introduction: Early life gut microbiomes are important for brain and immune system development in animal models. Probiotic use has been proposed as a strategy to promote health via modulation of microbiomes. In this observational study, we explore if early life exposure to probiotics via the mother during pregnancy and lactation, is associated with decreased inflammation in breastmilk, maternal and infant microbiome variation, and altered infant neurodevelopmental features. Methods: Exclusively breastfeeding mother-infant dyads were recruited as part of the "Mothers and Infants Linked for Healthy Growth (MILk) Study." Probiotic comparison groups were defined by exposure to maternal probiotics (NO/YES) and by timing of probiotic exposure (prenatal, postnatal, total). C-reactive protein (CRP) and IL-6 levels were determined in breastmilk by immunoassays, and microbiomes were characterized from 1-month milk and from 1- and 6-month infant feces by 16S rDNA sequencing. Infant brain function was profiled via electroencephalogram (EEG); we assessed recognition memory using event-related potential (ERP) responses to familiar and novel auditory (1 month) and visual (6 months) stimuli. Statistical comparisons of study outcomes between probiotic groups were performed using permutational analysis of variance (PERMANOVA) (microbiome) and linear models (all other study outcomes), including relevant covariables as indicated. Results: We observed associations between probiotic exposure and lower breastmilk CRP and IL-6 levels, and infant gut microbiome variation at 1- and 6-months of age (including higher abundances of Bifidobacteria and Lactobacillus). In addition, maternal probiotic exposure was associated with differences in infant ERP features at 6-months of age. Specifically, infants who were exposed to postnatal maternal probiotics (between the 1- and 6-month study visits) via breastfeeding/breastmilk, had larger differential responses between familiar and novel visual stimuli with respect to the late slow wave component of the EEG, which may indicate greater memory updating potential. The milk of mothers of this subgroup of infants had lower IL-6 levels and infants had different 6-month fecal microbiomes as compared to those in the "NO" maternal probiotics group. Discussion: These results support continued research into "Microbiota-Gut-Brain" connections during early life and the role of pre- and postnatal probiotics in mothers to promote healthy microbiome-associated outcomes in infants.

Breastmilk use in preterm infants <29 weeks' gestational age in Australia, New Zealand and Singapore.

AIMS: To describe the prevalence of use of breastmilk and explore demographic characteristics and clinical outcomes associated with breastmilk provision in infants born <29 weeks' gestational age in Australia, New Zealand and Singapore. METHODS: This is a secondary analysis of data from a randomised controlled trial, which enrolled 1273 infants in 13 neonatal units across Australia, New Zealand and Singapore from 2012 to 2015. Infants were classified as formula-fed, donor milk-fed or mother's milk-fed at their first enteral feed and separately, at hospital discharge. RESULTS: The percentage of infants receiving mother's own milk differed between centres both at first feed (79% to 100%), and at hospital discharge (47.1% to 71.6%). Aboriginal, Torres Strait Islander and Southeast Asian heritage, drug use and smoking were associated with lower rates of fully breastmilk feeding at hospital discharge. There was no significant difference in growth outcomes, length of stay and feeding tolerance between feeding groups. CONCLUSIONS: Achieving high breastmilk feeding rates at hospital discharge for all preterm infants born <29 weeks' gestational age at hospital discharge is possible; however, targeted support for mothers who are Indigenous, Southeast Asian and/or using recreational drugs and/or smoking and/or experiencing social disadvantage may be needed. A better understanding and shared knowledge of practice variations within neonatal units with high breastfeeding rates could improve breastmilk access and equity for preterm infants. AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY: ACTRN12612000503820.

Enhancing human milk studies: Introducing a less invasive human milk collection technique for the measurement of fatty acids.

OBJECTIVES: The fatty acid supply of human milk (HM) contributes to health outcomes. Sampling fresh human milk to analyze its fatty acid content is challenging because of its ever-changing nature. Also, obtaining samples from lactating mothers is challenging. Facilitating HM collection and analysis is therefore an advantage. METHODS: We have conducted a study to validate a new method for obtaining HM samples for fatty acid analysis, using biological fluid sample collection pretreated sheets to adsorb drops of milk (Whatman 903 BHT-pretreated biological fluid collection sheet) as an alternative approach to collecting expressed milk. The study population included lactating mothers, enrolled between 24 and 96 h after delivery. RESULTS: A total of 124 breastmilk samples were analyzed using the two distinct approaches. The results of the free milk analysis were comparable to the analysis of adsorbed milk samples. The fatty acid families saturated fatty acids (SFA), monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA), omega-3, and omega-6 had r2 values of 0.93, 0.91, 0.91, 0.86, and 0.90, respectively. Bland-Altman plots showed a high agreement between fresh and adsorbed milk samples for SFA, MUFA, PUFA, omega-3, and omega-6 with a mean bias <2% and 95% limits of agreement within -5% and +5%. CONCLUSIONS: The results show no significant differences in fatty acid composition between fresh and adsorbed milk samples, suggesting the new method is equally effective in collecting representative samples for analysis.

A longitudinal study of breastmilk feeding duration, EEG power and early academic skills.

BACKGROUND: The cognitive benefits of breastfeeding are widely recognized; however, its effects on brain development and later academic skills require further examination. This study aimed to examine the longitudinal relations between breastmilk feeding, neurophysiological changes, and early academic skills. METHODS: In the Growing Up in Singapore Towards healthy Outcomes (GUSTO) birth cohort, breastmilk feeding practices were collected every 3 months from 3 weeks to 18 months postpartum. Resting electroencephalography (EEG) was recorded at 18 months and power spectral density was derived. The outcomes were a set of early academic assessments administered at age 4 (n = 810). Structural equation modelling was used to investigate EEG power as a mediator between breastmilk duration and early academic skills. RESULTS: Breastmilk feeding for ≥12 months was associated with better general knowledge, numeracy, and language at age 4 compared to shorter durations of breastmilk feeding (Cohen's d: 1.53-17.44). Linear regression showed that breastmilk duration was negatively and positively associated with low- (i.e., delta, theta) and high-frequency power (i.e., gamma), respectively (Cohen's f2: 0.03-0.09). After adjusting for demographic and child baseline covariates, a decrease in absolute and relative delta, as well as relative theta was associated with better general knowledge and numeracy (Cohen's f2: 0.16-0.25). Relative delta power provided an indirect path between breastmilk duration and early academic skills (x2: 18.390, p = 0.010; CFI: 0.978; TLI: 0.954; RMSEA: 0.040). CONCLUSIONS: Extended breastmilk feeding is associated with reduced low-frequency power and better early academic skills, suggesting benefits to brain development. Additional research to confirm this finding is warranted.

Neonatal Linear Immunoglobulin A Bullous Dermatosis: A Critical Case Recovering after Prompt Recognition, Intensive Management, and Breastfeeding Interruption - A Case Report.

INTRODUCTION: Neonatal linear immunoglobulin A (IgA) bullous dermatosis (NLABD) is a rare, life-threatening, mucocutaneous bullous disorder. The pathogenesis and optimal treatment remain poorly defined and raise critical clinical challenges. CASE PRESENTATION: We present a case of a full-term female infant with severe cutaneous and respiratory symptoms due to NLABD. Diagnosis was confirmed by immunofluorescence on the infant's skin biopsy, while IgAs directed against the basement membrane of the skin and mucosa were identified in the mother's milk. The infant fully recovered after nearly 8 weeks of intensive multidisciplinary care, including non-invasive ventilation, nutritional support, wound care, systemic corticoid treatment, and breastfeeding discontinuation. CONCLUSION: This case underscores the importance of timely adequate diagnosis and management of this rare and serious condition. Moreover, it adds novel evidence documenting the presence of pathogenic IgAs in breastmilk.

Regulatory Effects of Maternal Intake of Microbial-Derived Antioxidants on Colonization of Microbiota in Breastmilk and That of Intestinal Microbiota in Offspring.

In this study, sixteen Sprague Dawley (SD) female rats and eight SD male rats were co-housed to mate. Pregnant SD female rats were fed with a control diet or an MA diet. Breast milk, maternal ileum, and intestinal samples of the offspring were collected at the day of birth and ten days afterwards. The results showed that the impact of MA was more obvious on the microbiota of mature milk (p = 0.066) than on that of colostrum. In addition, MA additive did not significantly affect maternal ileal microbiota, but affected offsprings' colonic microbiota significantly ten days after birth (p = 0.035). From the day of giving birth to ten days afterwards, in addition to the increase in microbial richness and diversity, at genus level, the dominant bacteria of breastmilk changed from Pseudomonas veronii to Bacillus and Lactococcus. Different from breastmilk microbiota, ten days after giving birth, the maternal ileal microbiota and the offsprings' intestinal microbiota were dominated by Lactobacillus. Instead of ileal microbiota, offsprings' colonic microbiota is a key action site of maternal MA additive. Therefore, the current findings have significant implications for the development of maternal feed aimed at modulating the intestinal microbiota of offspring, ultimately leading to improved health outcomes for both mothers and their offspring.

Microbiota regulates neonatal disease tolerance to virus-evoked necrotizing enterocolitis by shaping the STAT1-NLRC5 axis in the intestinal epithelium.

Microbiota and feeding modes influence the susceptibility of premature newborns to necrotizing enterocolitis (NEC) through mechanisms that remain unknown. Here, we show that microbiota colonization facilitated by breastmilk feeding promotes NOD-like receptor family CARD domain containing 5 (Nlrc5) gene expression in mouse intestinal epithelial cells (IECs). Notably, inducible knockout of the Nlrc5 gene in IECs predisposes neonatal mice to NEC-like injury in the small intestine upon viral inflammation in an NK1.1+ cell-dependent manner. By contrast, formula feeding enhances neonatal gut colonization with environment-derived tilivalline-producing Klebsiella spp. Remarkably, tilivalline disrupts microbiota-activated STAT1 signaling that controls Nlrc5 gene expression in IECs through a PPAR-γ-mediated mechanism. Consequently, this dysregulation hinders the resistance of neonatal intestinal epithelium to self-NK1.1+ cell cytotoxicity upon virus infection/colonization, promoting NEC development. Together, we discover the underappreciated role of intestinal microbiota colonization in shaping a disease tolerance program to viral inflammation and elucidate the mechanisms impacting NEC development in neonates.

Prenatal vitamin C and fish oil supplement use are associated with human milk microbiota composition in the Canadian CHILD Cohort Study.

Maternal diet may modulate human milk microbiota, but the effects of nutritional supplements are unknown. We examined the associations of prenatal diet and supplement use with milk microbiota composition. Mothers reported prenatal diet intake and supplement use using self-administered food frequency and standardised questionnaires, respectively. The milk microbiota was profiled using 16S rRNA gene sequencing. Associations of prenatal diet quality, dietary patterns, and supplement use with milk microbiota diversity and taxonomic structure were examined using Wilcoxon signed-rank tests and multivariable models adjusting for relevant confounders. A subset of 645 mothers participating in the CHILD Cohort Study (originally known as the Canadian Healthy Infant Longitudinal Development Study) provided one milk sample between 2 and 6 months postpartum and used prenatal multivitamin supplements ≥4 times a week. After adjusting for confounders, vitamin C supplement use was positively associated with milk bacterial Shannon diversity (ß = 0.18, 95% CI = 0.05, 0.31) and Veillonella and Granulicatella relative abundance (ß = 0.54; 95% CI = 0.05, 1.03 and ß = 0.44; 95% CI = 0.04, 0.84, respectively), and negatively associated with Finegoldia relative abundance (ß = -0.31; 95% CI = -0.63, -0.01). Fish oil supplement use was positively associated with Streptococcus relative abundance (ß = 0.26; 95% CI = 0.03, 0.50). Prenatal diet quality and dietary patterns were not associated with milk microbiota composition. Prenatal vitamin C and fish oil supplement use were associated with differences in the milk microbiota composition. Future studies are needed to confirm our findings and elucidate mechanisms linking maternal supplement use to milk microbiota and child health.

The Role of Breastmilk in Macrophage-Tumour Cell Interactions in Postpartum Breast Cancer.

BACKGROUND: Lactation is associated with long-term reduced risk of breast cancer. However, there is a transient increased risk of breast cancer in the 5 to 10 years postpartum and this is associated with a high incidence of metastasis and mortality. Breastmilk is a physiological fluid secreted by the mammary glands intimately connected with breast cells and the microenvironment that may affect postpartum breast cancer development and progression. This study aims to investigate the effect of breastmilk on interactions between breast cancer cells and macrophages in vitro. METHODS: Human breastmilk from healthy donors (n = 7) was pooled and incubated with breast cancer (MCF-7 and MDA-MB-231) and macrophage (RAW264.7) cell lines to assess cell proliferation, viability, migration, and expression of key genes associated with epithelial-mesenchymal transition (EMT) and macrophage phenotype. Indirect co-culture studies assessed the effect of breastmilk on interactions between breast cancer cells and macrophages. RESULTS: Breastmilk increased the proliferation and viability of breast cancer cells, reduced EMT markers, and reduced cell migration in MDA-MB-231 cells. Breastmilk decreased mRNA expression of interleukin 1B (IL1B) and interleukin 10 (IL10) in macrophages. Reduced EMT marker expression was observed in breast cancer cells co-cultured with macrophages pre-treated with breastmilk. Macrophages co-cultured with breast cancer cells pre-treated with breastmilk exhibited increased expression of a pro-inflammatory cytokine tumor necrosis factor A (TNFA) and pro-inflammatory nitric oxide synthase 2 (NOS2), and reduced expression of cytokines IL10 and transforming growth factor B1 (TGFB1) which are associated with the alternatively-activated macrophage phenotype. CONCLUSIONS: Breastmilk has the potential to promote breast cancer proliferation, however, it can also reduce breast cancer progression through inhibition of breast cancer cell migration and regulation of macrophage polarisation. These findings suggest that breastmilk has potential to shape the tumour microenvironment in postpartum breast cancer.

A landscape analysis of investors in the global breast milk substitute industry to target for advocacy.

The International Code of Marketing of Breast-milk Substitutes and subsequent resolutions (the Code) was adopted to address increases in mortality and morbidity resulting from the practices of the breast-milk substitute (BMS) industry. The lack of success in ensuring company compliance with the Code has prompted advocates to consider engaging with investors to shape the governance of BMS companies. To support these efforts, this paper aimed to identify prominent investors in the global BMS industry and explore their Code-related policies and practices. Using multiple methods and data sources, we developed a novel approach to identify and rank investors in the world's leading publicly listed BMS companies. We also examined the policies and voting behaviour of a sample of investors using publicly accessible materials from 2020 to 2022. We found that a small number of large investors, led by BlackRock and Vanguard, hold a substantial share in the global BMS industry. Of the top-10 ranked investors, only Norway's Government Pension Fund (NBIM) reported policy information relating specifically to BMS marketing. Most of these large investors also opposed the sample of public health-related shareholder proposals analysed. In addition, we identified several investors that have reported engaging with BMS companies on Code-related issues, including NBIM, Pictet, and UBS, along with several potential investor targets for future advocacy efforts, including some North American public pension funds. The inclusion of Code-related issues as part of broader policies, disclosures and regulations related to environmental, social and governance oriented investment warrants increased attention.

Topical review: Lactation and use of DMTs in women with MS.

One in three females with multiple sclerosis (MS) becomes pregnant after diagnosis. In the postpartum period, there is a risk of rebound inflammatory activity. This risk can likely be reduced with breastfeeding, as well as with early initiation of effective therapies that have low therapeutic lag. To guide patients in their choices surrounding breastfeeding and MS therapies, clinicians must be familiar with how best to protect against relapses, to ensure infant safety, and to support breastfeeding choices. This topical review provides a broad framework on lactation in women with MS. It seeks to reframe guidelines around caring for the maternal-infant dyad, and for diverse populations living with MS. It also provides updated data on the effects of lactation in women with MS and the limited data on transfer of disease-modifying therapies (DMTs) into breastmilk. The ultimate goal is to support informed shared decision-making between clinicians and patients regarding breastfeeding during the high-risk postpartum period.

Achievements and Challenges in Breastfeeding During Two Years of War in Ukraine.

Background: This article informs about the state of breastfeeding in Ukraine after more than 2 years of war. The article presents important information on breastfeeding data, the widespread implementation of the baby-friendly hospital initiative, human milk banks working in difficult situations, the first overestimation of breast milk substitute needs, the International Code, and the presence of donations reaching an overburdened health system. It covers the training of health care professionals as well as counseling in wartime. Conclusion: It is a testimony of important work done on different levels of the Ukrainian population as well as among the aid agencies present and the health system to protect and support breastfeeding for infants and mothers' health in a war situation. The acquired breastfeeding knowledge through BFHI training of health care professionals and the whole package of BFHI measures is important for ensuring the health and survival of children.

The effect of the implementation of the international code of marketing of breast-milk substitutes on child mortality in Ghana and Tanzania.

OBJECTIVE: The International Code of Marketing of Breast-Milk Substitutes is an important instrument to protect and promote appropriate infant and young child feeding and the safe use of commercial milk formulas. Ghana and Tanzania implemented the Code into national legislation in 2000 and 1994, respectively. We aimed to estimate the effects of the Code implementation on child mortality (CM) in both countries. SETTING: The countries analysed were Ghana and Tanzania. PARTICIPANTS: For CM and HIV rates, data from the Institute for Health Metrics and Evaluation from up to 2019 were used. Data for income and skilled birth rates were retrieved from the World Bank, for fertility from the World Population Prospects, for vaccination from the Global Health Observatory and for employment from the International Labour Organization. DESIGN: We used the synthetic control group method and performed placebo tests to assess statistical inference. The primary outcomes were CM by lower respiratory infections, mainly pneumonia, and diarrhoea and the secondary outcome was overall CM. RESULTS: One-sided inference tests showed statistically significant treatment effects for child deaths by lower respiratory infections in Ghana (P = 0·0476) and Tanzania (P = 0·0476) and for diarrhoea in Tanzania (P = 0·0476). More restrictive two-sided inference tests showed a statistically significant treatment effect for child deaths by lower respiratory infections in Ghana (P = 0·0476). No statistically significant results were found for overall CM. CONCLUSION: The results suggest that the implementation of the Code in both countries had a potentially beneficial effect on CM due to infectious diseases; however, further research is needed to corroborate these findings.

Method Validation Study for SARS-CoV-2 Viral RNA Detection in Cervical, Rectal, Amniotic Fluid, Placental, Umbilical Cord Blood, and Breastmilk Specimens in a Cohort of Unvaccinated Women in Manila, Philippines.

Objectives: To validate a method in detecting SARS-CoV-2 via RT-qPCR in pregnant and non-pregnant samples other than nasopharyngeal swabs and/or oropharyngeal swabs such as cervical, rectal, amniotic fluid, placental, umbilical cord blood, and breastmilk. Methods: We performed a validation experiment using MGI easy extraction kits and BGI PCR kits on non-conventional specimens, including cervical, rectal, amniotic fluid, placental, umbilical cord blood, and breastmilk to detect and confirm the presence of SARS-CoV-2. In addition, we tested the validated method on 572 purposively sampled field-collected non-conventional specimens from a cohort of 109 unvaccinated pregnant and 47 unvaccinated non-pregnant women to assess which candidate non-conventional maternal- and fetal-associated specimens may contribute to maternal-fetal viral vertical transmission. Results: Positive detection of SARS-CoV-2 viral RNA in non-conventional specimens was demonstrated and verified. Of the 572 non-conventional samples tested, 1.8% (10/572) were positively validated by RT-qPCR for SARS-CoV-2 in the maternal-associated specimens particularly the rectal (5), placental (1), and cervical (4) swabs among six pregnant and four non-pregnant individuals. In contrast, no SARS-CoV-2 viral RNA was detected in fetal-associated specimens. CONCLUSION: The results of the validation study may serve as an additional diagnostic screening layer to support maternal-child care. Furthermore, viral detection in these non-conventional maternal specimens may also be utilized to provide guidance in the clinical management of neonates, and pregnant women during delivery.

Lactic acid bacteria isolated from women' breast milk and infants' faeces have appreciable immunogenic and probiotic potentials against diarrheagenic E. coli strains.

Diarrheal diseases remain the leading cause of high mortality among the infants, particularly in the developing countries; Probiotic intervention for diarrhea has been an ongoing novel approach to diarrheal prevention and treatment. This study aims to characterize immunogenic and probiotic properties of lactic acid bacteria (LAB) isolated from human breast milk and neonates' faeces. The LAB isolates from 16 mothers' breast milk and 13 infants' faeces were screened and identified by 16 S rRNA gene partial sequencing. Their antimicrobial activities against 5 strains of diarrheagenic Escherichia coli were tested. Organic acids production was quantified by HPLC, and antibiotic resistance pattern were determined by VITEK®. Autoaggregation, co-aggregation and hydrophobicity properties were assessed by UV spectrophotometry and immunomodulatory effect was determined in mouse model. Ninety-three LAB of five genera were identified. The most abundant species was Lactiplantibacillus plantarum with inhibition zones ranged from 8.0 to 25.0 ± 1 mm. Lacticaseibacillus rhamnosus A012 had 76.8 mg/mL lactic acid, (the highest concentration), was susceptible to all antibiotics tested. L. plantarum A011 and L. rhamnosus A012 were highly resistance to gastrointestinal conditions. L. rhamnosus A012 produced hydrophobicity of 25.01% (n-hexadecane), 15.4% (xylene) and its autoaggregation was 32.52%. L. rhamnosus A012 and L. plantarum A011 exert immunomodulatory effects on the cyclophosphamide-treated mice by upregulating anti-inflammatory cytokine and downregulating proinflammatory cytokines. Lactobacillus sp. demonstrated good probiotic and immunomodulatory properties. Further works are ongoing on the practical use of the strains.

Outcomes of implementing the International Code of Marketing of Breast-milk Substitutes as national laws: a systematic review.

BACKGROUND: The International Code of Marketing of Breast-milk Substitutes, or 'the Code,' sets standards to regulate marketing of commercial milk formula (CMF) to protect breastfeeding. World Health Organization member states are advised to legislate the Code into national law, but understanding of its implementation outcomes is limited. This systematic review aimed to examine implementation outcomes in countries implementing the Code as national law. METHODS: We systematically searched five academic databases in September 2022 for articles published in English from 1982 to 2022. We double-screened titles/abstracts and then full texts for eligible articles reporting implementation outcomes of the Code in 144 eligible countries. We used the Mixed Methods Appraisal Tool for quality assessment and synthesized data thematically. We applied the Proctor et al. framework to guide synthesis of implementation outcomes, organizing our findings according to its taxonomy. RESULTS: We included 60 eligible articles of the 12,075 screened, spanning 28 countries. Fifty-seven articles focused on legal compliance, 5 on acceptability, and 1 on feasibility. Compliance was assessed across multiple sources, including mothers, health workers, media, points of sale, and product labels. Maternal exposure to CMF promotion remained widespread, with reports of mothers receiving free samples and coupons, and encountering media advertisements. Compliance of health workers varied across countries, with many reporting contact with CMF companies despite legal prohibitions. Public hospitals generally showed better adherence to the national law than private ones. While implementing the Code as national law effectively regulated the promotion of CMF for infants aged 0-12 months in public settings and in the media, it remains insufficient in addressing the promotion of unregulated products like growing-up milk, which are often marketed through emerging strategies such as cross-promotion and digital advertising. Point-of-sales compliance was inconsistent, with many countries reporting non-compliant price-related promotions. CONCLUSION: To enhance legal compliance, robust monitoring and reporting systems are necessary. Utilizing technology-assisted solutions for monitoring compliance can be an option for countries with limited human resources. Adequate training for health workers and communication strategies targeting shop managers about national law are also essential in enhancing their acceptability and compliance.