Trending Topics

Trending Topics pieces (Article Analyses, Evidence Clips and Other Topics) are published in timely response to recent media and journal articles, position statements, clinical guidelines, etc. Since they are based on the most recent evidence/publications, they may not be consistent with PEN evidence in other PEN content areas. As soon as possible, when this occurs, the PEN content will be reviewed and updated as needed.

• U.S. Report of Heavy Metals in Manufactured Infant Foods

  A U.S. report finds heavy metals in manufactured infant foods. Should we be concerned? Are heavy metals present in infant foods at unsafe levels? What should dietitians be advising parents to do? The PEN Team went looking for answers.

  
  

  What’s Happening?

  The Subcommittee on Economic and Consumer Policy of the U.S. House of Representatives released a report stating that some products and ingredients marketed for infants contained high levels of toxic heavy metals (1). Assuring the safety of infant foods is essential for the healthy development of children, so the PEN Team decided to review the Committee’s report to determine the extent of the toxic heavy metals in foods manufactured for infants.

  
  

  Findings

  The heavy metals examined in the report included arsenic, lead, cadmium and mercury (1). These findings were gathered from four food manufacturers’ submitted test results. Looking at Table 1, arsenic levels in the tested infant food products were found to be as high as 180 parts per billion (ppb), lead as high as 50 ppb, cadmium 344 ppb and mercury, although rare, was as high as 10 ppb.
   
  To determine if the levels of heavy metals were too high, the report presented a number of benchmarks (1). The main benchmark used for each of the heavy metals was the U.S. Food and Drug Administration (FDA) established standards for maximum allowable levels in drinking water (see Table 1). However, Codex (Food and Agricultural International Food Standards) specifies that the maximum acceptable level for arsenic in food is 20 times the maximum acceptable level in water and for lead the difference is 10 times (2). The PEN Team wonders about using maximum levels for drinking water as the basis of comparison, since Codex guidelines recognize that water levels need to be lower than food, as water is consumed in greater quantities than food (2). We also noticed that none of the food products reported exceeded the Codex maximum levels for these metals in foods (see Table 1).
   
  When the PEN Team took a closer look at the Subcommittee’s report, we discovered that most of the testing for heavy metals was on the individual ingredients used to create the infant food products (1). Few finished food products were specifically examined. The ingredient with the highest amount of arsenic was amylase enzyme and the highest amount of lead was in one of the cinnamon samples (1). Both of these ingredients are likely present in very small quantities in foods. Therefore, one cannot generalize the findings of high heavy metal contents of individual ingredients directly to the finished food product because we cannot know how high the true amounts of heavy metals are in infant foods when only the contents of ingredients are reported.
   
  Some ingredients that might be used in larger quantities had high amounts of arsenic (rice is known to accumulate arsenic as the plant grows) (3). For example, samples of organic rice flour from two different food manufacturers had amounts of 570 ppb (Beechnut sample) and 390 ppb (Hain sample) (1). These samples were both high compared to the FDA recommendation of no more than 100 ppb for infant rice/rice products (4) and Codex maximum level of 200 ppb for rice (2). However, those samples were unusually high as 92% of the other rice flour samples had arsenic between 100 and 200 ppb. Foods marketed as “organic” were as high or higher than those produced through conventional agriculture (1).
  
  
  Table 1: Comparison of the Subcommittee Report Findings with International and U.S. National Guidelines for the Maximum Levels of Heavy Metals for Drinking Water and Foods 

  In Parts per Billion	Subcommittee Report:  Maximum in an Infant Food (1)	Codex: Food Maximum Level (2)	FDA: Food Maximum Level for Infant Food (4)	Codex: Drinking Water Maximum Level (2)	FDA: Drinking Water Maximum Level (4)
  Inorganic Arsenic	180	200	100 for infant rice cereals	10	10
  Lead	50	100 for foods, 200 for grains, 500 for meats	Not established	10	5
  Mercury	10	Not established	Not established	1	2
  Cadmium	344	Not established	Not established	3	5

  Establishing safety levels of heavy metals in foods is very complex. It requires careful consideration of many factors, including the concentration in the food, the amount consumed and its frequency, and the body size of the consumer (5). For a comprehensive review of the safety of arsenic in infant foods, see the PEN Trending Topic: Do New Parents or Parents-to-be Need to be Concerned About Dietary Arsenic Exposure?
   
  Globally, the concentration of arsenic in rice and rice products is a common concern (5). In contrast to the findings of the Subcommittee report, studies from Health Canada and Food Standards Australia New Zealand found that the arsenic content of rice is lower than maximum permitted levels (6,7). In the U.K. where arsenic in some samples of rice exceeded the European Union Standards, the recommendation is to limit rice fed to infants to 20 g/day (8). 
  
  

  What Now?

  Rice, products made from rice, and fruit juices are foods that are typically higher in arsenic and these foods have historically been recommended or given to young children (5). Current advice is to give young children some meat as a source of easily absorbed iron, to offer a variety of infant cereals and grains, and to limit fruit juice (9). These strategies will help to keep young children’s arsenic intakes lower (5).
   
  Until safe standards are established, the PEN Team recommends:
  • People of all ages eat a variety of foods (10).
  • Rather than purchasing foods specifically marketed for infants/children, young children's transition to eating a variety of food is best supported through family foods. Infants have difficulty obtaining sufficient iron, so dietitians should emphasize the importance of iron-rich foods (meat, meat alternatives and fortified infant cereals made from a variety of grains) (9).
  • Dietitians are also encouraged to advocate for the development of heavy metal national standards for infant foods in all countries, including:
    • safe limits determination
    • standardization of testing
    • transparency and labelling of amounts in manufactured infant foods.
   
  See Additional Content: Food Safety - Arsenic in Rice Background.
  
  
  The PEN Team would like to thank Becky Blair for contributing to this Trending Topic.
   
  References
  1. Subcommittee on Economic and Consumer Policy. Committee on Oversight and Reform. U.S. House of Representatives. Baby foods are tainted with dangerous levels of arsenic, cadmium, lead and mercury. 2021 Feb 4. Available from: https://oversight.house.gov/sites/democrats.oversight.house.gov/files/2021-02-04%20ECP%20Baby%20Food%20Staff%20Report.pdf
  2. Food and Agriculture Organization, United Nations. General standard for contaminants and toxins in food and feed (CODEX STAN 193-1995). Adopted in 1995. Revised in 1997, 2006, 2008, 2009. Amendments 2010, 2012, 2013, 2014, 2015, 2016, 2017, 2018, 2019. Available from: http://www.fao.org/fao-who-codexalimentarius/sh-proxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FStandards%252FCXS%2B193-1995%252FCXS_193e.pdf
  3. U.S. Food and Drug. Arsenic in rice and rice products risk assessment. 2016. Available from: https://www.fda.gov/food/science-research-food/cfsan-risk-safety-assessments (under Downloads)
  4. U.S. Food and Drug Administration. Metals in your food. 2020 Aug 24. Available from: https://www.fda.gov/food/chemicals-metals-pesticides-food/metals-and-your-food
  5. Dietitians of Canada. Trending Topic - Do new parents or parents-to-be need to be concerned with dietary arsenic exposure? In Practice-based Evidence in Nutrition [PEN]. May 2018. Available from: https://www.pennutrition.com/resourcestools.aspx?trcatid=496&trid=26806&sr=arseniccbabiedcbabiescbabycbabying. Access by subscription only.
  6. Canadian Food Inspection Agency. 2011-2013 arsenic speciation in selected foods. 2018 Sep 4. Available from: https://www.inspection.gc.ca/food-safety-for-industry/food-chemistry-and-microbiology/food-safety-testing-bulletin-and-reports/arsenic-speciation-in-selected-foods/eng/1467179764138/1467179789317
  7. Food Standards Australia New Zealand. Arsenic. January 2020. Available from: https://www.foodstandards.gov.au/consumer/chemicals/arsenic/Pages/default.aspx#:~:text=There%20are%20limits%20in%20the,a%20level%20of%202mg%2Fkg
  8. Menon M, Sarkar B, Hufton J, Reynold C, Reina V, Young S. Do arsenic levels in rice pose a health risk to the UK population? Ecotoxicol Environ Saf. 2020 Jul 1:197:110601. Available from: https://pubmed.ncbi.nlm.nih.gov/32302858/
  9. Dietitians of Canada. Infant Nutrition - Complementary Feeding Summary of Recommendations and Evidence. In: Practice-based Evidence in Nutrition [PEN]. 2019 Aug 06. Available from: https://www.pennutrition.com/KnowledgePathway.aspx?kpid=2503&trcatid=42&trid=2514 Access by subscription only.
  10. Dietitians of Canada. International Dietary Guideline Collection. In: Practice-based Evidence in Nutrition [PEN]. 2021 Jan 11. Available from: https://www.pennutrition.com/KnowledgePathway.aspx?kpid=3127&trid=19399&trcatid=27 Access by subscription only. 

  

  Posted: 2021-03-02
  

  • PEN Applied, 
  • Infants 

• Vitamin D Update: Supplementation and Pregnancy and Perinatal Outcomes and 25-hyroxy-vitamin D as a Marker for Nutrient Deficiency and Sufficiency

  Vitamin D has been a very active area of research in recent decades. Not only have there been numerous research studies published, there have also been numerous systematic reviews published summarizing these studies. Recently, researchers in Alberta, Canada undertook a systematic review of the systematic reviews that investigated the importance of vitamin D in pregnancy for important perinatal and infant outcomes (1).
  
  This systematic review of systematic reviews found 42 systematic reviews of 204 primary studies that evaluated either vitamin D supplementation in pregnant women and/or examined the association between serum vitamin D levels for at least one predefined perinatal outcome (1). The researchers evaluated the systematic reviews for research quality using the AMSTAR tool and only analyzed data from the 13 systematic reviews with high AMSTAR scores. 
  
  The systematic reviews of randomized controlled trials (RCTs) with the highest quality of evidence showed no benefits from vitamin D supplementation regarding preterm birth, preeclampsia, gestational diabetes, stillbirth, low birth weight or caesarean section (1). A significant difference was found for small-for-gestational age; however, this evidence was low quality for two reasons: 1) the high risks of bias in the included studies without an accompanying sensitivity analysis to examine the low risk of bias studies separately, and 2) imprecision due to the small numbers of small-for-gestational age births in the included studies. Systematic reviews of observational studies showed that women with low 25-hyroxy-vitamin D levels had higher rates of preterm birth, preeclampsia, gestational diabetes and small-for-gestational age. 
  
  The findings of this systematic review (1) reinforce the findings of a 2017 systematic review (2) that found that the superior health of people with higher vitamin D serum levels suggested by the frequent associations observed in observational studies are not seen in randomized trials of vitamin D supplementation. Additionally, there is increasing evidence that serum 25-hyroxy-vitamin D, the vitamin D status marker, is a negative acute phase reactant, which decreases in response to other variables (2-9). Specifically, researchers have observed that 25-hyroxy-vitamin D decreases in response to inflammation (3), acute illness (4), ill health (2), critical illness (5), surgery (6,7) and when C-reactive protein increases (3,7-9). If a marker changes in response to other variables, then it has limited use as a nutritional adequacy marker.
  
  References

  1. Bialy L, Fenton T, Shulhan-Kilroy J, Johnson DW, McNeil DA, Hartling L. Vitamin D supplementation to improve pregnancy and perinatal outcomes: an overview of 42 systematic reviews. BMJ Open. 2020 Jan 20;10(1):e032626. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/31964667
  2. Autier P, Mullie P, Macacu A, Dragomir M, Boniol M, Coppens K, et al. Effect of vitamin D supplementation on non-skeletal disorders: a systematic review of meta-analyses and randomised trials. Lancet Diabetes Endocrinol. 2017 Dec;5(12):986-1004. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/29102433
  3. McMillan DC, Maguire D, Talwar D. Relationship between nutritional status and the systemic inflammatory response: micronutrients. Proc Nutr Soc. 2019 Feb;78(1):56-67. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/30220267
  4. Kostoglou-Athanassiou I, Pantazi E, Kontogiannis S, Kousouris D, Mavropoulos I, Athanassiou P. Vitamin D in acutely ill patients. J Int Med Res. 2018 Oct;46(10):4246-57. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/30157690
  5. Czarnik T, Czarnik A, Gawda R, Gawor M, Piwoda M, Marszalski M, et al. Vitamin D kinetics in the acute phase of critical illness: a prospective observational study. J Crit Care. 2018 Feb;43:294-9. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/28968524
  6. Binkley N, Coursin D, Krueger D, Iglar P, Heiner J, Illgen R, et al. Surgery alters parameters of vitamin D status and other laboratory results. Osteoporos Int. 2017 Mar;28(3):1013-20. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/27826645
  7. Waldron JL, Ashby HL, Cornes MP, Bechervaise J, Razavi C, Thomas OL, et al. Vitamin D: a negative acute phase reactant. J Clin Pathol. 2013 Jul;66(7):620-2. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=23454726
  8. Kruit A, Zanen P. The association between vitamin D and C-reactive protein levels in patients with inflammatory and non-inflammatory diseases. Clin Biochem. 2016 May;49(7-8):534-7. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=26778547
  9. Silva MC, Furlanetto TW. Does serum 25-hydroxyvitamin D decrease during acute-phase response? A systematic review. Nutr Res. 2015 Feb;35(2):91-6. Abstract available from:      https://www.ncbi.nlm.nih.gov/pubmed/?term=25631715
  Posted: 2020-02-07
  

  • Infants, 
  • Vitamins & Minerals, 
  • Pregnancy 

• Arsenic in Rice Products for Children

  A recent CBC Marketplace program reported on the testing of the levels of arsenic in rice cereals and snacks for infants and children. For an in-depth examination and analysis of the evidence on the topic of arsenic in the diets of infants and children, see the 2018 PEN Trending Topic: Do New Parents or Parent-to-be Need to be Concerned About Dietary Arsenic Exposure?. For further information on rice and arsenic, see: PEN's Food Safety - Arsenic in Rice Background.
  
  The Bottom Line
  Limit or avoid giving infants and young children cereals made from brown rice flour and products with brown rice syrup, since they have more arsenic. Some rice is okay for young children, but it is best to give infants and children a variety of grains and use infant rice cereals and rice-based products, such as wafers and crackers, in moderation. 

  Posted: 2019-03-06
  

  • Food, 
  • Infants, 
  • Children 

• Malnutrition in Infants Fed Plant-based Beverages

  Cases (n=34) of protein-energy malnutrition have been described in France among infants who were fed plant-based beverages/drinks (age at diagnosis 8.8 + 3.8 months) (1). These cases were discovered when pediatricians were asked to see these children because of fatigue or a growth deficit. One of these infants died, one-third had malnutrition, 29% (10/34) had a seizure, one suffered from respiratory distress and one had a bone fracture. Among the children who had blood work done, 60% (12/20) had anemia, 55% (11/20) had hypoalbuminemia, and 40% (8/20) had hyponatremia. The children were all fed plant-based drinks, mostly almond, chestnut and rice drinks. Previous reports involved smaller numbers of children (2).     
  
  The infants’ health improved after resuming a normal infant diet (which was not described), although one-third of the parents were not happy about the change in diet (1). The parents stated that their main influencers to give the plant-based drinks to their infants were the media (44%) and “alternative medical professionals” (38%). The researchers attributed the malnutrition to the low protein and energy contents of these drinks. 
  
  Although it is not possible to state with certainty that the malnutrition was caused by the plant-based drinks, the fact that 30 children (who were assessed) overcame their illnesses when placed on a normal infant diet suggests that this was the case. These cases may represent the health halo, a belief that these drinks are healthier than other choices. 
  
  For information on the recommendations for the use of plant-based beverages in infants, see PEN^® Practice Question: What are the recommendations for the use of plant-based beverages (e.g. soy, rice, almond, coconut and oat milk/beverage) during the complementary feeding period in infants?
  
  References

  1. Lemale J, Salaun JF, Assathiany R, Garcette K, Peretti N, Tounian P. Replacing breastmilk or infant formula with a nondairy drink in infants exposes them to severe nutritional complications. Acta Paediatr. 2018 Jun 20. doi: 10.1111/apa.14437. [Epub ahead of print]. Citation available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=29923219.
  2. Dietitians of Canada. Trending Topics: Plant-based Beverages – Are They Really Healthier for Young Children? In: Practice Based Evidence in PEN^® [PEN]. 2017 Aug 29. Available from: http://www.pennutrition.com/resourcestools.aspx?trcatid=496&trid=26285&sr=plant-based#. Access only by subscription.
  Posted: 2018-07-06
  

  • Infants, 
  • Plant-based Diet 

• Introduction of Allergenic Food to Infants, Especially Peanuts: Interim Guidelines for Canadian Dietitians

  This interim DC communication provides DC members with information on the scientific evidence regarding the introduction of peanuts to infants and how the current dietetic practice recommendations agree and differ from NIAID recommendations published in January 2017. In brief, the key differences between these new NIAID guidelines and current Canadian Nutrition for Healthy Term Infant (NHTI) recommendations are in the different definitions of “at risk” infants, the strength of wording for introducing peanut containing food early, and the recommendation to undergo physician supervised testing/feeding before introduction for a small subset of very high-risk infants . Refer to the full document for more information. See also the PEN Evidence Clip : Food Allergy Prevention in Infants.

  Posted: 2017-01-23
  

  • Food Allergy, 
  • Infants 

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