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Proposed Changes to NHMRCs 2012 Infant Feeding Guidelines submission

ID: 
14
This submission reflects the views of
Organisation Name: 
Nestlé Australia Ltd (Nestlé)
Please identify the best term to describe the Organisation: 
Commercial company – other
Personal Details
Question 1
Do you agree with the proposed change? If no, please provide rationale and relevant citations: 
Nestlé comments – Yes – Nestlé agrees with the principles for the proposed changes but with some additional important amendments: We agree that the use of soy or goat’s milk-based formulas is not recommended for reducing the risk of allergies. ASCIA recommends that for allergy prevention, infants who are not breastfed should be fed a partially hydrolysed infant formula – “In Australia and New Zealand only partially hydrolysed formulas (usually labelled ‘HA’ or Hypoallergenic) are recommended for allergy prevention” (ASCIA, 2010). This is in-line with the most recent recommendations, following systematic reviews of all available evidence, of major international associations such as AAAAI 2013 & EAACI 2014, which were both published after the NHMRC IFG’s were released. We note that EAACI 2014 viewed this as Level 1 evidence with a grade of ‘A-B’, making it the strongest of all of their recommendations in this area (Muraro et al., 2014). Given the high rates of allergy in Australia and the fact that 50% of Australian infants are considered at high-risk of allergy (Su et al, 2012), it is important for NHMRC to make a clear recommendation regarding allergy prevention. Therefore we suggest the following amendment to reflect the above: “There is no evidence that the use of soy or goat’s milk-based formulas will prevent the development of allergies to cow’s milk-based formulas. If breastmilk is not available, partially hydrolysed formulas should be used for allergy prevention.” We agree that goat’s milk-based formulas are not suitable alternatives for infant with allergies to cow’s milk-based formulas. We note current Australian paediatric allergy consensus advice (Kemp et al., 2008) is to use extensively hydrolysed formulas for these infants, particularly those less than 6 months. Amino acid formula is recommended as first choice in anaphylaxis and eosinophilic oesophagitis (Kemp et al., 2008). Soy formulas can be utilised for infants over 6 months but are not recommended for infants under 6 months (Kemp et al., 2008). This is reinforced in the DRACMA Guidelines produced by the World Allergy Organisation (Fiocchi et al., 2010). Therefore we suggest amendment to: “Goat’s milk-based formulas are not suitable alternatives for infants with allergies to cow’s milk-based formulas.” “Infants under 6 months of age with allergies to cow’s milk protein should use an extensively hydrolysed formula under medical supervision or, in certain circumstances, an amino-acid based infant formula. Infants over the age of 6 months with allergies to cow’s milk protein may be recommended a soy based formula in the first instance.” Accordingly, with the above proposed changes, Nestlé considers that the elaborations of the summary points are reviewed for alignment with the summary. Currently, Section 8.5.1 is about “Preventing allergies in infants with a family history”, however, also includes under this heading recommendations around dietary management of a diagnosed cow’s milk protein allergy and other conditions. We are of the view that the 2 topics – Allergy prevention (infants with a family history) and Dietary management of a Diagnosed cow’s milk allergy, should be separated, and would suggest that recommendations around the latter is best suited under Section 8.5.2 “Formulas for managing other infant conditions”. Advice for parents in both sections should accordingly be reviewed. In the area of allergy, we also note that significant systematic reviews have been undertaken by the European Association of Allergy & Clinical Immunology on primary prevention of allergy (2014), and that in the near future, ASCIA plans to review the evidence in the area. As such we would request NHMRC considers a subsequent update of the Infant Feeding Guidelines, to reflect the latest body of evidence when key scientific bodies have published the outcomes, as well as to immediately give regard to these new systematic reviews from EAACI. References ASCIA, 2010 Infant Feeding Advice. http://www.allergy.org.au/health-professionals/papers/ascia-infant-feeding-advice AAAAI, 2013. Primary prevention of allergic disease through nutritional interventions: Guidelines for healthcare professionals, Physician Reference Card. American Academy of Allergy, Asthma, and Immunology. Muraro et al, 2014. EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy. Allergy 2014; 69: 590-601. Kemp et al, 2008. Guidelines for the use of infant formulas to treat cows milk protein allergy: an Australian consensus panel opinion. MJA 2008; 188: 109-112. Fiocchi et al, 2010. World Allergy Organisation (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines. Pediatric Allergy & Immunology 2010; 3(4): 57-161. Su et al, 2012. Cost-effectiveness of partially-hydrolyzed formula for prevention of atopic dermatitis in Australia. Journal of Medical Economics, 2012, 15 (6); 1070-1083.
Question 2
Do you agree with the proposed change? If no, please provide rationale and relevant citations: 
Nestlé comments – Yes – Nestlé agrees with the proposed change.
Question 3
Do you agree with the proposed change? If no, please provide rationale and relevant citations: 
Nestlé comments – Breast milk is the best nutrition for infants. Nestlé believes that continued breastfeeding during the introduction of complementary foods is very important for public health. Nestlé considers that with the recent review of Minimum age labelling on infant foods in the Food Standards Code 2.9.2 and the outcome that the status quo of the youngest minimum age labelling permitted on infant foods is from 4 months, that the wording could be amended to ensure clarity and alignment of National guidelines with Food Regulation. “Around 6 months” was initially defined in the draft NHMRC guidelines (Oct 2011) as 22-26 weeks, which is not aligned to “From 4 months” (17 weeks as per ESPGHAN, 2009). An accumulating body of scientific evidence suggests a potential window of opportunity to reduce allergic responses in infants by the introduction, not avoidance, of solid foods, between 4 and 6 months of age. This is recognised by national and international competent authorities and scientific bodies such as EFSA (2009), ESPGHAN, American Academy of Paediatrics, ASCIA, and confirmed in recent and well-designed Australian and international studies. Therefore, for the age for introduction of solids to be consistent with the accumulating evidence around the reducing risk of food allergies, we consider that the wording needs to be clearer and aligned to minimum age labelling of From 4 months, consistent with the ASCIA Infant Feeding advice (2010) and the recent positions from AAAAI (2013) and EAACI (2014). It is Nestlé’s view that the recommended minimum reference age of ‘around 6 months’’ is confusing. References ESPGHAN Agostoni C, et al. Breast-feeding: A Commentary by the ESPGHAN Committee on Nutrition, JPGN, 2009, 49: 112-125. ASCIA, 2010 Infant Feeding Advice. http://www.allergy.org.au/health-professionals/papers/ascia-infant-feeding-advice AAAAI, 2013. Primary prevention of allergic disease through nutritional interventions: Guidelines for healthcare professionals, Physician Reference Card. American Academy of Allergy, Asthma, and Immunology. Muraro et al, 2014. EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy. Allergy 2014; 69: 590-601.

Page reviewed: 16 September, 2015