2. METE, E et al. Antifungal Effect of Human, Cow’s Milk, Formulas Turk J Med Sci
Introduction were separated into eight groups. The first group (group
Breast milk contains various antimicrobial substances, 1, n =10 dishes) was used to detect the fungal flora of
factors that promote immune development, constituents the environmental air. The second group (group 2, n =
that promote tolerance/priming of the infant immune 10 dishes) was rubbed with a thin layer of human milk by
system, as well as anti-inflammatory components (1). a sterile pipette. The third group (group 3, n =10 dishes)
These substances in human milk not only modulate and was rubbed with 0.9% NaCl solution to determine
mature the immune system of premature or mature whether the depletion of fungal growth in human
newborns but also protect them against infections. The milk–rubbed dishes was only caused by the prevention of
incidence of gastrointestinal and respiratory infections in contact of air to the agar or the antifungal effect of the
infants receiving human milk is lower than in those not human milk. Fourth group (group 4, n = 10 dishes) was
breast-fed, because of the presence of the specific rubbed with a thin layer of fresh cow’s milk. Fifth, sixth,
antibody and antiadhesion molecules in human milk (2). seventh and eighth groups (group 5,6,7,8, n=10 dishes
While many studies have focused on the anti-bacterial and each one) were rubbed with a thin layer of probiotic
anti-viral effects of milk or milk constituents, there are formula, prebiotic formula, pro-prebiotic formula and
only few studies concerning the possible anti-fungal infant formula (without pro-prebiotic) respectively. After
effects (3). Infant formula on the market today should be 7 days of incubation, the colony-forming fungal growths
aimed at providing the best alternative to breast milk for of all dishes were evaluated, counted, and recorded by a
infants of those women who are unable to continue microbiologist who did not know the groups of the dish
breastfeeding. For these purposes, the following numbers (7).
compounds have been added to formula: long-chain The study, carried out at Fatih University School of
polyunsaturated fatty acids, probiotics, prebiotics and Medicine was approved by the local ethics committee and
nucleotides (4). A number of studies involving the feeding conducted in accordance with the ethical principles
of probiotics and prebiotics to infants have been described by the Declaration of Helsinki.
published over the last decade (5). These studies have
Statistical Analyses
examined a wide range of health outcomes, including
growth rates of infants, safety profile of formula, All statistical analyses were performed using the SPSS
prophylaxis and alleviation of diarrheal disease, reduction for Windows, version 13.0 (Chicago, IL, USA). Unless
in atopic diseases, necrotizing enterocolitis, and infections otherwise stated, results were expressed as means ±
of the preterm infant. In addition, these studies have standard deviation for numerical values and percentage
described microbiological alterations observed in for categorical values. Nonparametric and parametric
response to probiotic and prebiotic feeding (6). As far as tests were used as appropriate. P < 0.05 was considered
we know, there is few previous studies that investigate statistically significant.
the antifungal effect of infant formula. The purpose of
the present study was to investigate the antifungal effect
Results
of human milk, infant formula and cow’s milk and
compare their antifungal effects. The fungal growths in all groups are shown in Table
1 and Figure 1. There was no statistically significant
difference between the number of fungal colonies grown
Material and Methods in control group and in the 0.9% NaCl group. The
Milk samples were obtained from lactating mothers of number of fungal colonies grown in human milk–rubbed
healthy term infants between the 3rd and 8th days of dishes in group 2 was less than all of the other groups
lactation after colostrum, with a breast pump, and the (groups 1, 3, 4, 5, 6, 7 and 8), which was statistically
milk was placed into sterile containers. All samples were significant except group 7 (P < 0.001, P < 0.001, P <
stored at 4°C and processed within 2 hours of collection. 0.001, P < 0.001, P < 0.05, P > 0.05, P < 0.0001,
Eighty Sabouraud agar petri dishes were used. After 15 respectively). The number of fungal colonies grown in
minutes uncovered in Ankara Emek district, in the same prebiotic-rubbed dishes in group 6 and pro-prebiotic-
location, on an unrainy day, all petri dish lids were closed rubbed dishes in group 7 was less than controls in group
and incubated at room temperature. Then, the dishes 1, and this difference was statistically significant
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3. Vol: 39
No: 1
Table 1. Colony-forming fungal growth in all groups.
Env. Fungal Flora Env. Fungal Flora Env. Fungal Flora Env. Fungal Flora Env. Fungal Flora Env. Fungal Flora Env. Fungal Flora Env. Fungal Flora
(Group 1) with Human Milk with % 0.9 NaCl with cow’s milk with probiotic formula with probiotic formula With pro+prebiotic formula With pro+prebiotic formula
(n = 10) (Group 2) (n = 10) (Group 3) (n = 10) (group 4) (n = 10) (group 5) (n = 10) (group 6) (n = 10) (group 7) (n = 10) (group 8) ( n = 10)
Number % (Ratio Number % (Ratio Number % (Ratio Number % (Ratio Number % (Ratio Number % (Ratio Number % (Ratio Number % (Ratio
of of colony of of colony of of colony of of colony of of colony of of colony of of colony of of colony
colonies to total) colonies to total) colonies to total) colonies to total) colonies to total) colonies to total) colonies to total) colonies to total)
Rhizopus 75 30.7 28 31.7 78 32.5 79 33.5 68 33.1 43 30.06 40 32.5 79 33.8
Cladosporium 59 24.1 21 23.9 54 22.7 55 23.5 43 20.9 34 24 28 22.7 53 22.5
Penicillum 35 14.3 9 10.3 28 11,7 25 10.8 25 12.1 17 11.8 17 13.5 28 12.1
Alternaria 21 8.6 9 9.7 20 8.5 24 10.1 19 9.2 15 10.8 11 8.9 22 9.4
Mucor 17 6.9 7 8.2 19 7.9 16 6.6 15 7.1 13 8.8 8 6.1 18 7.5
Aspergillus 15 6.1 6 7.1 16 6.8 13 5.4 13 6.5 10 6.9 7 5.8 14 6.1
Hormodendrum 9 3.5 3 3.8 10 4 7 2.9 9 4.2 5 3.7 4 3.1 8 3.3
Lacaria 5 1.9 2 2.21 5 2.03 7 3 6 3.1 2 1.6 4 2.9 4 1.8
Monilia 4 1.5 1 1.06 4 1.6 3 1.2 3 1.4 2 1.39 2 1.6 4 1.7
Stemphyllium 2 0.8 1 1.1 3 1.12 3 1.27 2 0.97 1 0.69 1 0.81 2 0.85
Antifungal Effect of Human, Cow’s Milk, Formulas
Myxomycele 2 0.81 1 1.1 2 0.83 3 1.2 2 0.97 1 0.69 1 0.81 3 0.12
Total 244 100 88 100 239 100 235 100 205 100 143 100 123 100 235 100
Mean number of
colonies ± standard 24.4 ± 11.0 28.8 ± 5.07 23.9 ± 9.08 23.5 ± 8.95 20.5 ± 2.91 14.3 ± 4.66 12.3 ± 5.22 23.5 ± 5.66
deviation
69
February 2009
4. METE, E et al. Antifungal Effect of Human, Cow’s Milk, Formulas Turk J Med Sci
Cummings et al. reported that phagocytosis and killing
35
effect on Candida albicans by milk macrophages were
30 identical to that of blood monocytes (12). Anderson et al.
reported that human milk showed potent inhibitory effect
25 on fungal growth and lactoferrin was responsible for the
95% Colony
20
fungistatic effect (3) .
In our previous study, we showed that human milk
15 has antifungal effect in vitro (2). Fungal growth was
significantly less in human milk–rubbed agars compared
10
to simple Sabouraud agars and 0.9% NaCl solution-
5 rubbed agars in that previous study suggesting an in vitro
Human Pre- Prebiotic Probiotic Standard Cow’s Isotonic Control antifungal effect of human milk. In presented study ,
milk probiotic formula formula formula milk
formula human milk showed same antifungal effect and we
Group
additionally found that there was significantly less fungal
Figure 1. The comparison of fungal colonies between groups. growth in human milk–rubbed agars than cow’s milk-
rubbed agars, probiotic formula- rubbed agars, prebiotic
formula-rubbed agars and standard infant
formula(without pro-prebiotic)-rubbed agars. This
(P<0.05, P<0.01, respectively). The number of fungal
situation may suggest that an in vitro antifungal effect of
colonies grown in cow’s milk –rubbed dishes in group 4,
human milk, which could be an important factor in
probiotic-rubbed dishes in group 5 and standard infant
protection from mycotic infections and allergic diseases in
formula (without pro –prebiotic) -rubbed dishes in group
breast-fed infants, is superior than cow’s milk and various
8 was less than controls in group 1 , but this difference
kinds of infant formula. Fungi threaten human life not
was not statistically significant. Cladosporium,
only by infections, but also by causing allergic reactions as
Alternaria, Aspergillus, Penicillium, Stemphyllium, Mucor,
aeroallergens (13). Before causing allergic reactions,
Hormodendrium, Lacaria, Monilia, Myxomycele and
mucosal blockage of fungi on entrance to the human body
Rhizopus sp. fungi were grown and fungus species were
can prevent the onset of allergic bronchitis, asthma, and
similar in all of the dishes. In the human milk group, the
skin diseases such as urticaria. Providing the production
number of fungal colonies was significantly lower, but the
of IgG-type blocking antibodies against the aeroallergens
percentages of fungal species were similar to the others.
such as fungi is one of the mechanisms of vaccination in
asthmatic patients (14). Because of its antifungal effect,
Discussion human milk may be proposed to protect infants from
allergic diseases caused by fungi via some mechanisms of
Studies in developed nations indicated a significantly
induction of cytokines and secretory IgA. Anderson et al
lower frequency and/or severity of disease in breast-fed
found that human skim milk inhibits growth of Candida
infants compered to those fed artificially (7). These
albicans and Rhodotorula Rubra, and this effect was
differences suggest that human milk has protective and
caused by lactoferrin through its iron-binding capacity. In
immunomodulatory activities that are lacking in even the
contrast, bovine milk had no inhibitory effects (3). The
best artificial formula (8). Recent reports associate
reason why cow’s milk and kinds of infant formula’s
artificial feeding of neonates with subsequent chronic
antifungal effect is lower than human milk may be the
diseases of later life, especially those with an autoimmune
lactoferrin levels; that kind of infant formula does not
component (10). A systematic review concluded that
contain lactoferrin and cow’s milk contains lower levels of
breast-feeding appears to protect infants from the
lactoferrin than human milk.
development of atopic diseases (eczema and food and
respiratory allergies), particularly if there is a family Fungal growth in human milk–rubbed agars was
history (11). While most studies have focused on anti- compared to pro-prebiotic formula-rubbed agars, but the
bacterial, anti-parasite and anti-viral activities, only few difference did not reach statistically significant ranks.
have focused on the anti-fungal effect of human milk (3). However, if we include more agars, it may reach
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5. Vol: 39 No: 1 Antifungal Effect of Human, Cow’s Milk, Formulas February 2009
statistically significant levels; because number of fungal probiotic microorganisms can not proliferate in Saburoud
colonies grown in human milk–rubbed dishes was less dishes. If probiotic microorganisms had grown in
than pro-prebiotic formula-rubbed agars and human milk Saburoud dishes, these microorganisms would have
have more antifungal effect than pre-probiotic formula. inhibited the fungal growth. Probiotics may play an
In the present study, we found that prebiotic and pre- important role in helping the body to protect itself from
probiotic formula have also antifungal effects and the infections, especially along the colonized mucosal surfaces
reason of this condition may be oligosaccharides in these of the gastrointestinal tract. Probiotic products are
formula. Prebiotics are nondigestible food components available in many different forms worldwide, including
that benefit the host by selectively stimulating the growth pills, powders, foods, and infant formula (18). Human
or activity of non-pathogenic bacteria in the colon. milk also contains probiotics (16). There is currently
Prebiotics (commonly oligosaccharides) added to infant insufficient evidence to recommend the addition of
feeds have the potential to prevent sensitization of infants probiotics for allergy prevention (19) Brouwer et al
to dietary allergens (15). Human milk also contains found that probiotic bacteria used in infants with Atopic
prebiotics (16). Oligosaccharides may be responsible in Dermatitis did not have clinical or immunological effect.
inhibition of fungal growth by stimulating the growth of Their results indicated that oral supplementation with
non-pathogenic bacteria in the dishes in our study. More these probiotic bacterial strains did not have a significant
recent studies have been able to show clinical benefits impact on the symptoms of infantile atopic dermatitis
with the use of a prebiotic mixture in infant formula. (20). The fact that probiotic formula did not have
Firstly, it has been shown to decrease the risk of antifungal effect may be contributed to this condition.
developing atopic dermatitis in high risk infants; secondly In conclusion, in vitro antifungal effect of human milk
a reduced incidence of intestinal as well as upper airway is significantly superior than cow’s milk and kinds of
infections in the first year of life. It can be hypothesized infant formula. Human milk is not only the best food for
that prebiotics might play an important role as a new infants but also it protects infants from fungal infections
concept in allergy and infection prevention in infants (17). and fungal allergies by means of antifungal effect. To
Antifungal effect of prebiotics and pre-probiotics may prevent infections and allergic diseases, human milk must
contribute to allergy and infection prevention in infants. be considered as the ideal food for newborns. Prebiotic
Because of these effects prebiotic or pre-probiotic and pre-probiotic formula have also antifungal effects.
formula can be preferred rather than probiotic formula Prebiotic or pre-probiotic formula should be preferred
and standard formula in infants who can not be fed with rather than standard formula and probiotic formula in
human milk. circumstances that human milk can not be given to infant,
Probiotic formula did not have any antifungal effect in due to the antifungal effects and decreasing the risk of
our presented study and the reason of this may be that atopic diseases and infections.
References
1. Hosea Blewett HJ, Cicalo MC, Holland CD, Field CJ . The 5. Agostoni C, Haschke F. Infant formulas. Recent developments and
immunological components of human milk. Adv Food Nutr Res. new issues. Minerva Pediatr 2003; 55(3): 181-94.
2008; 54: 45-80.
6. Veereman-Wauters G. Application of prebiotics in infant foods. Br
2. Mete E, Bavbek N, Dayı S, Erkmen M, Andıran F. In Vitro Antifungal J Nutr 2005; 93: Suppl 1: S57-60.
Effect Of Human Milk. Allergy Asthma Proc 2006; 27: 412-14.
7. Smith GE. Allergic fungus. In Sampling and Identifying Allergenic
3. Andersson Y, Lindquist S, Lagerqvist C, Hernell O. Lactoferrin is Pollens and Molds. San Antonio, Texas: The CV Blewstone Press,
responsible for the fungistatic effect of human milk. Early Hum 1990; 73–74.
Dev 2000; 59: 95–105.
8. Howie PW, Forsyth JS, Ogston SA, Clark A, Florey CD .
4. Kliegman RM, Marcdante KJ, Jenson HB, Behrman RE. Nelson Protective effect of breast feeding against infection. BMJ 1990;
Essential of Pediatrics. Pediatric Nutrition and and Nutritional 300: 11–16,
Disorders. Nutrition of The Normal Infant. Krebs NF , Primak LE.
5. Ed. Elsevier Health Sciences. 2005; 131-136.
71
6. METE, E et al. Antifungal Effect of Human, Cow’s Milk, Formulas Turk J Med Sci
9. Newburg DS, Walker WA. Protection of the Neonate by the Innate 15. Osborn DA, Sinn JK. Prebiotics in infants for prevention of
Immune System of Developing Gut and of Human Milk. Pediatr allergic disease and food hypersensitivity. Cochrane Database Syst
Res 2007; 61: 2-8. Rev 2007; 17(4): CD006474.
10. Hanson LA, Ceafalau L, Mattsby-Baltzer I, Lagerberg M, 16. Coppa GV, Bruni S, Morelli L, Soldi S, Gabrielli O. The first
Hjalmarsson A, Ashraf R, et al. The mammary gland-infant prebiotics in humans: human milk oligosaccharides. J Clin
intestine immunologic dyad. Adv Exp Med Biol 2000; 478: Gastroenterol 2004; 38(6 Suppl): S80-3.
65–76.
17. Moreno Villares JM. Prebiotics in infant formulae. Could we
11. Field JC. The immunological components of human milk and their modify the immune response? An Pediatr 2008; 68(3): 286-294.
effect on immune development in infants. J Nutr 2005; 135:
18. Sanders ME. Probiotics: considerations for human health. Nutr
1–4.
Rev 2003; 61(3): 91-9.
12. Cummings NP, Neifert MR, Pabst MJ, Johnston RB Jr. Oxidative
19. Tang ML, Robinson M. Allergy prevention - Current
metabolic response and microbicidal activity of human milk
recommendations and new insights. Aust Fam Physician 2008;
macrophages: Effect of lipopolysaccharide and muramyl
37(4): 204-208.
dipeptide. Infect Immun 1985; 49: 435– 439.
20. Brouwer ML, Wolt-Plompen SA, Dubois AE, van der Heide S,
13. Middleton E, Reed CE, Ellis EF, Adkinson F, Allergy. Principles
Jansen DF, Hoijer MA et al. No effects of probiotics on atopic
and practice. Aerobiology and Inhalant Allergens. Solomon WR,
dermatitis in infancy: a randomized placebo-controlled trial. Clin
Platts-Mills TAE. (Ed.). St.Louis, Washington DC, Toronto:The
Exp Allergy 2006; 36(7): 899-906.
C.V. Mosby Comp, 1998; 367–393.
14. Durham SR, Till SJ. Immunologic changes associated with allergen
immunotherapy. J Allergy Clin Immunol 1998; 102(2): 157-64.
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