It is no secret that breastfeeding is the Cinderella choice for an infant’s nutrition compared to the unpopular stepsister known as formula. Most healthcare professionals recommend that mothers breastfeed for at least the first six months of their child’s life, continuing until two years of age if possible, because of the fundamental nutrients breast milk provides for infants. [1] While maternal milk is simply regarded as “just food,” many don’t realize it is also a sophisticated and intricate food source that has evolved over millions of years to provide infants with nutrition, protection and components of information necessary for their growth, development and maturity in early life. [2] Recommendations to breastfeed are often heavily pushed onto mothers because of this intricate system’s ability to adjust over time according to a baby's changing needs, especially within their first few months of life. 

So if you can't breastfeed, or choose not to, you’re not invited to the Royal Ball?

The decision to breastfeed or formula feed can be a difficult choice for many parents, especially mothers. For mothers who can’t breastfeed or those whose breast milk is deemed insufficient, infant formulas as a substitute are used to satisfy the needs of infants.[3] Common misconceptions and stigmas surrounding formula feeding often cause parents to have feelings of guilt for choosing formulas over breastfeeding, even when formula is the only option for their child. The ideology that “babies fed formula will not grow up as healthy as babies breastfed” weighs heavily on parents, oftentimes making them feel they are making the wrong choice for their child’s health. [3] 

However, within the past century, formula feeding has grown to be increasingly popular worldwide, despite the stigmas that exist. Advancements in infant formulas containing fortified prebiotics have even been released with ingredients more similar to human milk. [1]  In a recently published study, a team of researchers put these new prebiotic formulas through a series of  tests to determine if they were in fact transitioning from the ugly stepsister status… “bippity boppity boo” … to becoming Cinderella, just like breast milk.

Did the Fairy Godmother’s magical spell work?

Researchers conducted a 12+ year study to investigate what effect these new fortified prebiotic formulas had on infants’ guts within the first 12 weeks of life. Our gastrointestinal (GI) tract, commonly called our “gut,” is one of the most important ecosystems that exist within our body. This ecosystem is made up of trillions of microorganisms that are not only important for the digestion of our food, but also for our ability to fight illnesses and diseases (our immune response). 

Breastmilk is a direct source of energy that plays a huge role in shaping an infant’s gut within the first few weeks of life. [4] It contains unique and complex prebiotics, such as oligosaccharides, that help support a healthy gut and protect newborns against infections. Prebiotics promote the growth of good bacteria within our gut microbiome ecosystem, which then act as a defense mechanism when unwanted viral pathogens and bad bacteria try to enter our body. Prebiotics and probiotics from breast milk work together to significantly lower the risks of infants getting infections. They also work together to increase diversity of good bacteria within the gut for increased health and immune tolerance.  

In order to investigate whether new prebiotic formulas are better resembling breast milk, researchers examined whether there were differences between the types of microbiota found in the guts of breastfed infants and that found in the guts of infants fed from formula with prebiotics or formula without prebiotics. They accomplished this by analyzing… wait for it…poop!

Mothers of infants born between 2002 and 2003 that were chosen to participate in the study, collected fecal samples from their child’s diaper at one month of age. They also indicated whether they breastfed their child, formula fed without prebiotics, or mixed fed (breastmilk and formula without prebiotics) their child during the first four weeks post-delivery (group 1). These fecal samples were then collected and explored by researchers so they could identify the types of microbiota present in the guts of infants based on their feeding type. 

Almost 12 years later, participant mothers of infants born in  2015 and 2016, repeated the same procedures of collecting fecal samples from their child’s diaper and indicated how their child was fed (breastfed only, formula fed with prebiotics or mixed fed with both breastmilk and formula with prebiotics). Although similar to the experiments done in 2002 and 2003, these samples were collected at weeks 2, 6 and 12 post-delivery (group 2).

The purpose of waiting an extensive amount of time (12+ years) between the collection of samples from group 1 (2002-2003) and the collection of samples from group 2 (2015-2016), was to test how formulas with and without prebiotics were affecting microbial development in infants’ guts. Those results were then compared to the control groups of infants that were only fed breast milk in both group 1 and group 2.

Does the glass slipper fit? 

The results suggested that fecal microbiota composition from infants fed formulas containing new fortified prebiotics (group 1, 2015-2016) were found to be more similar to fecal microbiota collected from infants that were only breastfed (control group from both groups 1 and 2). However, infants that were not fed formulas with prebiotics (group 2, 2002-2003) and infants that were mixed fed (from both groups 1 and 2) unfortunately did not have this trend observed by researchers. This suggests that new fortified prebiotic formulas are better mimicking breast milk's effect on the development and maturation of an infants’ gut in early life.

The shoe does fit!... Right?...

Well…

While researchers found evidence that infants fed the new prebiotic formulas had similar microbiota composition as infants that were breastfed, the results also showed that formula fed infants had higher levels of bacterial diversity in their gut compared to the lower levels of bacterial diversity observed in the guts of infants that were breastfed. Higher levels of bacteria diversity within an infant’s gut means that the prebiotic formulas are speeding up the maturation of the gut microbiota ultimately resembling more adult-like composition within the first few weeks of life.[4]

A previous study, that specifically looked at how early life trajectories may influence the development of celiac disease, suggested that higher levels of bacterial diversity in the gut microbiome within the first few weeks of life (2-6 weeks) can actually be extremely harmful to a child’s health as they grow in age.[5] The researchers expressed that infants with “premature maturation” of the gut effects immune tolerance putting infants at a higher risk of being more susceptible to illnesses and diseases later in life.[5] Yet, there is no direct evidence that has been found supporting this idea that formula feeding results in a child later developing celiac disease. 

The findings that infants fed formula had higher levels of bacterial diversity in their gut is surprising because usually diversity within our gut microbiome is a good thing. Since  more microbiota richness makes our immune system stronger and more stable, increased diversity is typically considered beneficial. Though, researchers specified that while speeding up the maturation of the gut microbiome might not seem so bad, timing of microbial development is extremely important. The colonisation of microbiota is complex and they need to gradually establish themselves in the gut over time since they play an important role in immune programmings.[4] Similarly, infants in early life, within the first 12 weeks, are not expected to resemble adult like microbial ecosystems but instead have low diversity and stability gradually increasing in richness over time.[4]

For the future, how do formulated milks become Cinderella?

As of right now, the results of this study are in line with previous findings that formulas with prebiotics are not in fact the new Cinderella compared to breast milk. Breast milk still remains the golden choice for infants’ nutrition and considered an important driving force in shaping early life gut microbial ecosystems.[4] On the other hand, this study made it clear that formulated milks have drastically improved over time, and the nutritional effect on infants’ gut microbiome have come a long way since the early 2000’s. 

While this study didn’t fully get the desired results, a major venture moving forward is figuring out ways to design formulas to better mimic the complex naturally changing prebiotics and proteins present in breastmilk. Oftentimes the same formula with uniform ingredients are used for infants from birth until age one, if not older. As mentioned previously, maternal breast milk has the ability to adjust to a baby's changing needs as they grow from being a few weeks old, to a few months old and finally reaching age one. Thus, creating formulas that change the amount of prebiotics, probiotics and proteins present over the first month of life may be a way to avoid unfavorable acceleration of microbial colonization in infants’ gut microbiomes.[4] 

Lastly, further research of breast milk composition can play a huge role in the development of better equipped prebiotic infant formulas. Human milk oligosaccharides (HMO’s) and other prebiotics have not yet been fully understood which complicates the process of developing formulas to mirror breast milk components. The more information that can be gathered the better chance formula milks have at becoming Cinderella and attending the royal ball!

Before the clock strikes midnight, Formula will have a chance to attend the Royal Ball! 

References 

1. 11 Benefits of Breastfeeding for Both Mom and Baby. In: Healthline [Internet]. 13 Aug 2020 [cited 25 Feb 2021].

Available: https://www.healthline.com/health/breastfeeding/11-benefits-of-breastfeeding

2. Rabin R. Breast-Feed or Else. The New York Times. 13 Jun 2006.

Available: https://www.nytimes.com/2006/06/13/health/13brea.html. Accessed 18 Feb 2021.

3. For All The Women Who Can’t Breastfeed: 20 Reasons It’s Okay. In: Moms [Internet]. 2 Jan 2019 [cited 25 Feb 2021].

Available: https://www.moms.com/for-all-the-women-who-cant-breastfeed-20-reasons-its-okay/

4. Borewicz K, Suarez-Diez M, Hechler C, Beijers R, de Weerth C, Arts I, et al. The effect of prebiotic fortified infant formulas on microbiota composition and dynamics in early life. Sci Rep. 2019;9: 2434. doi:10.1038/s41598-018-38268-x

5. Olivares M, Walker AW, Capilla A, Benítez-Páez A, Palau F, Parkhill J, et al. Gut microbiota trajectory in early life may predict development of celiac disease. Microbiome. 2018;6: 36. doi:10.1186/s40168-018-0415-6

6. 2,366 Breastfeeding Illustrations & Clip Art - iStock. [cited 18 Feb 2021].

Available: https://www.istockphoto.com/illustrations/breastfeeding

7. What Are Prebiotics? In: WebMD [Internet]. [cited 25 Feb 2021].

Available: https://www.webmd.com/digestive-disorders/prebiotics-overview

Raven Truxson (’22) DC Posse Scholar Junior at Bucknell University working towards a B.S. in Biology and Minor in Sociology while on a Pre-Med track. 

Interested in becoming a Pediatrician or OBGYN! This past school year I have conducted research through the Bucknell Sociology Department and in partnership with the United Way looking at the overall performance of the new Free2BMom program that services pregnant women addicted to opiates. I will be continuing sociology research this summer with the United Way as well examining how childhood traumas in PA communities such as Shamokin leads to negative health outcomes later in life. We are looking at what preventative measures and interventions can be put in place to lower these “negative” outcomes as a result of past traumas or experiences. I will also be working at Children’s Hospital in DC this summer doing research and data analysis on childhood opportunity and healthcare outcomes in the DMV area. I will work with my team as well as individually to compile effective policies to address racial disparities, creating documents and interview guides and statistically analyzing childhood opportunity (reflected in educational offerings, environmental factors, family income levels, etc.).

Outside of my research, I am the President of the minority medical club on campus known as SNMA-MAPS. We are a small chapter on campus a part of a larger national organization. I am also an RA on campus and will be returning as an RA for the 2021-2022 school year. Lastly, I am the Class of 2022 representative on the Arts and Sciences Curriculum Committee. 

Post-graduation I plan on participating in a full-time gap year program while studying for my MCAT before continuing my education in Medical School. I hope to find either a research position or a position in the hospital to full my gap year with hands on meaningful experiences in either one of the fields I am interested in, or a specialty that sounds interesting to me to try something new out of my comfort zone and broaden my knowledge/ skills. I also love to travel and hope to travel as a doctor one day to help others in need!