Milk Infant Formula

Just Accepted by Toxicology Mechanisms and Methods
Neonatal animal testing paradigms and their suitability for testing infant formula
Edwin G. Flamm doi: 10.3109/15376516.2012.725108 Abstract
Toxicology Mechanisms and Methods Downloaded from informahealthcare.com by 85.210.39.49 on 09/09/12 For personal use only.
Due to the ever increasing number of substances added to infant formula, and the fact that the majority of data determining the safety of these substances has been derived from adult animals, a search of the available data was performed to determine if an appropriate neonatal model could be found that could be used for performing toxicological safety studies. This exercise utilized three different forms of media. The first informational source is from a publication from the Institute of Medicine (IOM) of the National Academies. The second form of informational data utilized was from simple YAHOO and Google Scholar searches on the internet. The third source of information was from the U.S. Food and Drug Administration (FDA), more specifically, the Center for Drug Evaluation and Review (CDER) preclinical guidance document. Following the examination of the above informational sources, it became apparent that neonatal rats and pigs have been the most utilized of the neonatal models. Following the evaluation of the papers the experimental paradigm which appears to be the most appropriate for testing substances new to infant formula, and could be used as a pivotal study was the neonatal pig utilizing the automated feeding device called the Autosow.
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Review NEONATAL ANIMAL TESTING PARADIGMS AND THEIR SUITABILITY FOR TESTING INFANT FORMULA
Edwin G. Flamm*
Division of Biotechnology and GRAS Notice Review, Office of Food Additive Safety Center for Food Safety and Applied Nutrition, U.S. Food and Drug Administration
Running title: Neonatal Animal Testing Paradigms
Keywords: Autosow, Colostrum, gavage, pup-in-a-cup
*The opinions expressed in this article are the authors personal opinions and do not necessarily reflect those of FDA, DHHS, or the Federal Government.
Corresponding author Edwin G. Flamm
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Division of Biotechnology and GRAS Notice Review, Office of Food Additive Safety Center for Food Safety and Applied Nutrition, U.S. Food and Drug Administration 5100 Paint Branch Parkway, College Park, MD 20740, U.S.A. Email: Edwin.Flamm@fda.hhs.gov Tel: 240-402-1285
Neonatal Animal Testing Paradigms
Abstract: Due to the ever increasing number of substances added to infant formula, and the fact
that the majority of data determining the safety of these substances has been derived from adult animals, a search of the available data was performed to determine if an appropriate neonatal model could be found that could be used for performing toxicological safety studies. This exercise utilized three different forms of media. The first informational source is from a publication from the Institute of Medicine (IOM) of the National Academies. The
second form of informational data utilized was from simple YAHOO and Google Scholar searches on the internet. The third source of information was from the U.S. Food and Drug Administration (FDA), more specifically, the Center for Drug Evaluation and Review (CDER) preclinical guidance document. Following the examination of the above informational sources, it became apparent that neonatal rats and pigs have been the most utilized of the neonatal models. Following the evaluation of the papers the experimental paradigm which appears to be the most appropriate for testing substances new to infant formula, and could be used as a pivotal study was the neonatal pig utilizing the automated feeding device called the Autosow.
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Introduction: Conventional wisdom is that the optimal diet, nutritionally and developmentally, for infants, is breast milk. However, various factors such as health, work demands, and other personal issues can make breast feeding impractical or impossible.
Manufacturers of infant formulas understand this and are constantly formulating new ingredients for infant formulas in order to better mimic natural breast milk. If the mothers milk is unavailable, infant formula will serve as the sole source of nutrition that the infant will receive for the first 6 months or so of life. The infant formula consumed must promote growth and normal development. Historically, adult animal studies for the most part have been used to determine the safety of new substances for infant formulas, mostly due to the difficulty of orally dosing neonatal animals. The purpose of this investigation is to determine if there are appropriate neonatal experimental models which could be used to either confirm or alleviate toxicological concerns pertaining to a new substance being added to an existing infant formula.
Methods: This investigation utilized three different areas or forms of media, which will be reported on separately prior to the conclusion. The first informational source is a publication from the IOM entitled: Infant Formula Evaluating The Safety Of New Ingredients (2004). The second form of informational data utilized was simple YAHOO and Google Scholar searches on the internet (Key Words: Neonatal, Toxicology Studies, Infant Formula, Oral, Gavage, Autosow, Pup-in-a-Cup and the particular animal species). The third source of information was from the
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FDA/CDER (2006) guidance document entitled: Guidance for Industry Nonclinical Safety Evaluation of Pediatric Drug Products.
Results and Discussion:

IOM: Chapter 5 of the IOM (2004) publication entitled: Testing Ingredients with Preclinical Studies was the most relevant chapter pertaining to this investigation. Biological and physiological considerations which must be considered before selecting an animal model was discussed in this chapter. An important criteria in choosing a model is that it should be at a similar developmental stage as the intended human consumer, in this case, an infant. In addition the model chosen should have similar metabolic and digestive characteristics as a human infant. Several different animal models were considered in the IOM publication with the bulk of the emphasis on primates, swine, rats, and mice. The following is a summation of the IOM publication pros and cons for these four animal models.
Primates:
This animal model tends to have a similar diet compared to humans and has no problem consuming infant formulas. Primates are highly comparable to humans, and were reported to be a good model for neurological studies. The IOM reported the stage of development between the human brain at 4 months of age and the primates at 1 month of age to be equivalent. The drawbacks of using primates are two-fold, extremely expensive, and many researchers are
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not willing to sacrifice primates especially if the researcher is only interested in one or two parameters.
Swine:
Like primates swine can consume high fat infant formulas, and they also metabolize fat in the same manner as do humans. Another similarity to humans is that piglets and neonatal humans are similar in size. According to the IOM publication pigs make an excellent model for lipid metabolism, hypoxia, and endocrinology studies. Pigs have also been used to investigate or study biochemical (fatty acids) aspects of the neuronal membranes and myelin sheath of the developing brain. Unlike primates, pigs can be more readily sacrificed in order to perform necessary analyses. The author of this article would like to add that since the pig is mostly thought of as a farm animal an millions of pounds of pork are consumed every year it is reasonable to conclude that researchers would be less hesitant to sacrifice swine than primates. The one drawback of using piglets at the present time according to the IOM is that they are not a good model for performing behavioral or neurodevelopmental toxicity testing, because they are hard to work with. Therefore it can be difficult to determine if an adverse effect occurred or not.
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Rodents: The pros and cons for rodents, specifically rats and mice are as follows. There is a vast amount of physiological, anatomical, biological, and behavioral information on the rat. One example
given, directly related to neonatal testing, made the correlation between the neonatal rat brain and the structural similarities at a given age to the neonatal human brain. For example the IOM publication reported that the maturity of the rat brain at postnatal day 7 is structurally similar to a 34 week premature human brain, and at postnatal day 12 the maturity of the rat brain was
reported to be structurally similar to the brain of a human that went full term. The rat was also reported to be a good behavioral model. The mouse was reported to be an excellent genetic model, due to our current knowledge of the genome of this species. The IOM publication reported that 45 to 55% of the calories consumed by the human infant are consumed as fat whereas the rat diet is normally around 5% fat. Therefore the rat is an inappropriate model for assessing the toxicological significance or lack thereof when altering fat levels. The mouse also consumes a low fat diet, and was reported to exhibit different tissue and liver lipid metabolism than humans. Feeding and dosing new substances for use in infant formulas to neonatal rodents is difficult. There was a procedure reported that is used to artificially rear neonatal rats, however, the procedure was reported to require gastrostomy placement. This procedure was reported to be invasive and difficult to maintain for very long. This procedure and variations thereof will be discussed later.
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Internet Searches: The next step of the investigation was to search the literature for different neonatal testing paradigms using YAHOO and Google Scholar. Since infant formulas are consumed orally the
reported data is mostly on oral and intragastric paradigms with a couple of exceptions. This is not to be thought of as an all inclusive list of oral neonatal studies, but a good representation of current neonatal methodologies. These are the relevant studies that were found using YAHOO and Google Scholar. Table 1 illustrates the different neonatal testing methods that are being
used at this time, and it gives a sense of which species are the most utilized.
Insert table 1 here.
Dogs:
From the results of the above literature search it is clear that there is a lack of orally dosed neonatal dog studies, at least published ones. Two orally dosed juvenile dog studies (not neonatal) were located. The first one was in juvenile dogs and was reported in Japanese with English abstract and tables (Sawada et al. 2001). The second one was an abstract and 8 weekold puppies were utilized (Clarke et al. 2001). In addition one very short abstract from Covance Laboratories (Grainger and Blakey 2000) was located. The abstract reported that Covance has been utilizing immature neonatal dogs, when testing pediatric drugs and biological substances. However, no particular study was reported.
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Primates: Three neonatal infant monkey studies were located. The first one gavaged monkeys ranging
in age from 30 minutes to 17 days old with monosodium glutamate (Stegink et al. 1975). Gavaging primates can have significant drawbacks in that it may cause them to vomit as occurred to a limited extent in the monosodium glutamate study. If vomiting does occur it has to be determined if the animal should be dosed again and with what portion of the first dose. This
would depend on when the animal vomited (how much time had passed since exposure) and the volume of vomit. Either way it will be difficult to know exactly how much of the compound was retained by the animal. The following two studies were bottle-fed at least when the studies first started and both dealt with docosahexaenoic acid and arachidonic acid added to formula (Champoux et al. 2002; Jeffrey et al. 2002). The formula used was a mixture of Similac and a commercial monkey formula. One of the studies indicated that the monkeys were hand-fed until they could feed themselves and that was reported to be usually by 3 days of age (Champoux et al. 2002). If you can afford to maintain primates for example, monkeys and are not concerned with the ethical issues that can arise from sacrificing primates, and you have the staff to bottle-feed primates, then the testing paradigm utilizing bottle-fed neonatal primates or monkeys would be a viable method for testing new substances for infant formula. This dosing procedure is non-invasive and primates are able to consume formula high in fat. However, as stated above there are significant drawbacks to using primates.
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Rodents (Mice and Rats): The differences in nutritional requirements between rats, mice and humans along with the
difficulty in feeding and dosing neonatal rats and mice makes these two species inadequate for testing infant formula where assurance of normal growth and development is of paramount importance. Two different methodologies and variations thereof were found that attempt to alleviate the dosing and feeding issue, unfortunately the techniques may lead to more
questions than answers. Not all of the listed neonatal rodent references are on substances pertaining to infant formula and are only referenced as a means of illustrating the dosing procedure.
Gavage:
The first methodology is to gavage the neonates (Dorman et al. 2000; Fukuda et al. 2004; Pan and Chen 2007; Flores et al. 1996; Pollack et al. 1987; Hsiao et al. 2001; Eriksson et al. 2002; Sand et al. 2004; Viberg et al. 2006; Butchbach et al. 2007). Neonates can be gavaged with just the test substance (no milk) and then returned to the dam for nursing, or the test substance can be mixed with a rat milk substitute or in the case of the mice studies, the vehicle was a 20% fat emulsion and gavaged in this manner (Eriksson et al. 2002; Sand et al. 2004; Viberg et al. 2006). In the second case the neonates would most likely be gavaged additional milk and they may even be returned to the dam for additional nursing. An article based on conclusions of the International Life Sciences Institute Risk Science Institute (ILSI RSI) Expert Working Group (Moser et al. 2005) reported that orally gavaging neonatal rodents can be done successfully with practice. The ILSI RSI Expert Working Group also reported on
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several factors which must be taken into consideration so that a negative maternal or neonatal response does not occur. For example, the technicians must wear gloves when handling the neonates and take measures to insure that the gavaged pups smell the same as the rest of the litter. Additionally, neonates that are injured in anyway or showing adverse health effects may be
rejected by the dam. The article also reports that the volume being administered must be carefully considered along with the viscosity of the vehicle in which the test substance is being administered. Moreover, gavaging neonates large volumes of a test substance and/or a highly viscous vehicle can interfere with nursing. Thus, dosing volumes should be much less than normal milk intake. One article reported on what was referred to as a novel way of orally dosing neonatal mice (Butchbach et al. 2007). The technique is a modified gavaging method which was reported to be less invasive than the typical gavaging method. The emphasis was on reporting a novel way of delivering drug compounds not infant formula. Neonatal mice 4 days old or younger are held gently by the skin on the back of the neck. A curved 25.4 mm long, 24-gauge feeding needle with a ball (rather than needlepoint) 1.25 mm in diameter is inserted into the mouth of the mouse. When the ball gets to the pharynx the compound is delivered slowly using a Hamilton microsyringe. The needle is then gently removed from the mouth of the neonate. The neonate is sometimes mildly sedated with isoflurane a gaseous anesthetic, prior to performing this procedure. This method was reported as being minimally invasive because the needle does not go down the esophagus and therefore can not cause any damage to the esophagus as normal gavaging can. In addition the procedure with a properly
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trained technician should only take 10 seconds, and only minimal effects were reported to have been observed in feeding and grooming behaviors between the neonates and the dams. The article reported that out of 955 neonatal mice being dosed in this manner only 46 died due to the procedure (4.8%). This is a very good success record, however even this modified gavaging
method is not completely non-invasive. In addition, it was reported that neonatal mice as young as 2 days of age have been dosed in this manner, but the risk of mortality is higher than in neonates at 4 days of age. The ILSI RSI Monograph (Zoetis and Walls 2003) reported on a procedure that sounds similar to the above mouse study (Butchbach et al. 2007). In this case, neonatal rats are orally administered a compound but just to the back of the mouth. The ILSI RSI Monograph (Zoetis and Walls 2003) reported this procedure to be relatively safe for the neonate but due to taste aversion or uncooperative pups, some of the dose that was administered may be lost (no particular study was referenced).
Artificially Reared Rodents:
The second methodology and variations thereof is to artificially rear rodent pups. This method is often called the pup-in-a-cup model (Flores et al. 1996; Hall 1975; Potsic 2002; Li et al. 2004; Ismail-Beigi et al. 2006; Wainwright et al. 1999; Srinivasan et al. 2000; Srinivasan et al. 2003; Kinirons et al. 2003; Patel and Srinivasan 2002; Aalinkeel et al. 1999; West DB et al. 1982; West JR 1993). Neonatal rats are reared either by intragastric cannulation where a feeding/dosing tube is inserted down the esophagus and into the stomach, or by gastrostomy
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placement where a feeding/dosing tube is surgically inserted into the stomach. Neonatal rats are then placed in Styrofoam cups and floated in a water bath which is kept at a constant temperature. Pumps which are on timers artificially feed and dose the animals. The pup-in-acup method is normally done on neonatal rat pups, however, one article was located (Beierle et
al. 2004) which performed the pup-in-a-cup method by surgically inserting a feeding tube into neonatal mice. Due to the complexity of the technique this method requires very experienced, well-trained technicians as noted in the ILSI RSI monograph (Zoetis and Walls 2003), and the procedure is not recommended for standard toxicological testing. This is also a time-consuming technique because the neonates must be removed from the cup every day so that the anogenital region can be stimulated by wiping it with a moist tissue so that the animals defecate and urinate. In addition, the tubing and litter must be cleaned and changed every day. The pup-in-a-cup procedure using the gastrostomy placement procedure to feed and dose the neonates is invasive because of the surgical procedure. The pup-in-a-cup method using the intragastric cannulation just like the gavaging methods can be stressful to the neonates and is an unnatural feeding method. One of the articles pointed out an additional problem to this technique and that is the possible problem of bloat (Kinirons et al. 2003). If the rate of flow is too great the neonates will bloat. In order to reverse bloating the flow must be reduced. However, in reducing the flow to combat the bloat the body weights of the neonates can be adversely affected. Due to differences in nutritional requirements and metabolism between rats and humans, and the stress that can be caused by the pup-in-a-cup method, it would be difficult to extrapolate the results using these
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procedures to the human condition and it would be even less likely to be a pivotal study that would confirm or alleviate toxicological concerns when dealing with substances for use in infant formula. However, the pup-in-a-cup methodology may have more research utility when testing non-nutritive substances such as alcohol especially pertaining to the brain. Due to the
comparative nature and structural characteristics of the neonatal rat brain and neonatal human brain at different stages of development which was reported on earlier from the IOM publication.
Non-Oral:
For the most part only oral studies were considered since infant formula would be consumed orally. The substance in this case went directly into the gastrointestinal tract in this immunological article (Kraehenbuhl and Campiche 1969) therefore it was included. Rats, rabbits and pigs were injected with immunoglobulin G directly into the jejunum. This procedure is acceptable for an immunological study. However, it would not be a practical method for dosing new substances for infant formula.
Rabbits:
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In addition to the immunological study which included the rabbit an additional study was located in which newborn rabbits were gavaged (Lee et al. 2000). Newborn New Zealand white rabbits were placed in an incubator on the day of delivery. The newborn rabbits were fed and dosed by gavage Lactobacillus GG twice a day for 2 days either alone or with E. coli
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(Escherichia coli) K1A and then were sacrificed on day 3 so that tissues could be harvested. The gavaging technique used in this study caused little trauma to the animals overall. However, it was reported that 2% of the neonates were excluded from the data either due to mortality, or trauma caused by gavaging which was evident by the appearance of regurgitated
blood.
Swine (Biology and Physiology):
There is another neonatal animal model which has similar nutritional requirements and is anatomically and physiologically similar to humans. This animal model is
the neonatal pig. Piglets (non-miniature) and human neonates are comparable in size at birth. The piglet however is slightly lighter at approximately 1.4 kilograms, but by day 8 the piglet is approximately 3 kilograms, and the body weight of the pig can increase up to 1000% from its initial birth weight by week six (Miller and Ullrey 1987; Ramirez et al. 1963). The significance of this rapid rate of growth is that nutritional deficiencies that can occur in both pigs and humans will make themselves apparent more rapidly. One example of this pertains to the lack of iron content in mothers milk of both humans and pigs which is approximately 1 part per million (Miller and Ullrey 1987). Due to the rapid growth of the piglets iron deficiency anemia is observed in piglets at 2 to 4 weeks of age if they do not receive any additional iron. Humans infants also suffer from iron deficiency anemia if they do not receive any other source of iron, but it takes 4 to 24 months to be evident (Book and Bustad 1974). The paper entitled:
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Information Resources on Swine in Biomedical Research 1990-2000 reports on the physiology and anatomy of the pig and can be found at www.nal.usda.gov/awic/pubs/swine/swine.htm. This
report was published by the U.S. Department of Agriculture and its agencies including: the Agricultural Research Service, the National Agricultural Library and the Animal Welfare Information Center. This paper reports on the anatomical similarities and differences of the organ systems between swine (non-miniature) and miniature breeds (Yucatan, Sinclair Hormel, Hanford and Gttingen to name a few) compared to humans. The main difference of course between these two different types of swine is size. Swine (non-miniature) at 4 months of age are approximately 100 kg and miniature swine are only half or less of this body weight depending on the breed. The difference in body weight gain would suggest that non-miniature piglets would be more appropriate for shorter term studies. Swine (non-miniature) also tend to have larger litters (8-12) than the miniature breeds (4-6). Epiphysial closure occurs by the time swine (non-miniature) are 3 to 4 years of age, this occurs in miniature swine approximately 1 to 2 years earlier. Organ systems discussed included but was not limited to the heart, gastrointestinal tract, kidney, skin and brain. The swine heart and the human heart are similar with one exception, the pig has a left azygous vein humans do not. There are anatomical differences in the gastrointestinal tract. However, the gastrointestinal tract of the pig has been used as a classic model for studying digestive phenomena in humans. The paper reports that the neonatal
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development of the gastrointestinal tract is similar to humans and that the physiological
characteristics of the gastrointestinal tract are also similar, most likely due to the fact that both pigs and humans are omnivores. The anatomy and physiology of the pig kidney is reported to be very similar to the human. The skin of the pig is thicker, less vascular
and has no sweat glands. The cutaneous blood supply however in pigs is similar to humans, and pigs have been used to study wound healing and certain plastic surgery procedures. Due to the massive bone structure of the skull the brain of the pig has not been studied much. However, the vascular structure of the brain is comparable to humans. The ILSI RSI Monograph (Zoetis and Walls 2003) reported that the neonatal pig is an ideal model for studying infant formula due to the similarities in nutrients needed and the physiology of the digestive tract of the neonatal pig compared to the human infant. Notable differences between piglets and neonatal humans are: Fat reserves are more limited in piglets than human infants, pigs lack the ability to sweat and have a higher metabolic rate and body temperature (Book and Bustad 1974). There has been a long held believe that piglets are born without circulating immunoglobulins due to the placental barrier. There is no doubt that piglets will receive the majority of immunoglobulins from the colostrum that is consumed while nursing. However, an article was located that reported low levels of immunoglobulins in the blood and certain organs of fetal pigs (Butler et al. 2001). The possibility of maternal contamination was discussed. Regardless if piglets are born with or without immunoglobulins colostrum consumption is essential for the survival of the piglet in a non-protected environment. This same article (Butler et al. 2001) shows that IgG serum levels are
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higher than IgA or IgM in the fetal pig. However, fetuses with the highest IgG levels are still
lower than a one day old neonate after nursing for a day by 1000 fold. Another article by the same lead author (Butler et al. 2009) reported the immunoglobulin level (IgM, IgG and IgA) in
the blood after 70 days gestation for fetal pigs to be small at 10-27 g/ml.
Swine Methodologies other than the Autosow:
The first neonatal pig methodology to be discussed mimics a low birth weight infant that cannot take food orally. This method has been developed to study substances administered by total parenteral nutrition (Wykes et al. 1993; Kansagra et al. 2003). Silastic catheters are surgically inserted and the neonatal pigs are intravenously fed compounds typically used in clinical settings through these catheters. This type of study design would take very experienced personnel, however, if you had a substance that was to be used in this manner, such a study as this may be worthwhile. Three additional oral neonatal study methodologies utilized one of the following: a bowl, (Pond et al. 1971) bottle-feeding, (Craig-Schmidt et al. 1996; Arbuckle et al. 1994; Wedig et al. 2002) or gavage (Stegink et al.1973). The concern with feeding a liquid diet from a bowl is spillage and determining what was actually consumed. However, the study that utilized bowls did not report that any spillage occurred. Bottle feeding neonates is a very viable way of dosing; however, it is time consuming. Gavaging is stressful and as reported earlier with the monkey study, the animals may vomit making it difficult to determine how much of the dose was retained. This particular study gavaged monosodium glutamate to neonatal pigs
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and did not report on any of the animals vomiting. One additional study utilized two different
dosing procedures, hand-fed (assuming bottle-fed) and a feeder which was used to feed the piglets after 2 days of hand-feeding (Hrboticky et al. 1990). This also seems to be a viable way
of dosing piglets and is an introduction to the next experimental feeding paradigm.
Autosow: North Carolina State University in Raleigh has been studying neonatal pigs for years and several articles on the subject have been written by individuals associated with this university (Lecce 1969; Lecce 1971; Lecce 1975; Lecce and Coalson 1976; Lecce et al. 1979; Lecce et al. 1982; Jones et al. 1977; Rhoads et al. 1990; Rhoads et al. 1992; Gomez et al. 1995; Gomez 1997; Ulshen et al. 1991). The current name of the laboratory facility at North Carolina State University is the Grinnells Intensive Swine Research Laboratory. This facility uses an automated feeding machine called the Autosow (general term for this type of machine) for dosing piglets. The Autosow works like a surrogate mother which not only feeds the piglets but also administers a specific amount of test substance. The idea of an automated system for raising piglets is not a new one. In 1949 the Wall Street Journal reported on a methodology where 2 day old piglets would be taken from their mothers and raised on synthetic sows milk in what was referred to as hog hatcheries (Lecce 1975). This was important due to the fact that many piglets did not survive because they were trampled by their mothers. Now instead of nursing her young the sow can have another litter. Pigs as noted earlier are born lacking sufficient circulating
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immunoglobulins and therefore are immunocompromised. The piglets acquire immunoglobulins

when they consume colostrum which they receive when they first start to nurse from the sow. However, piglets are infected with pathogens from the sow during birthing and while nursing.
Therefore the longer the piglets are left with the sow to nurse, the effects of E. coli and Rotavirus infections will manifest themselves in the piglets as diarrhea. There are 3 basic ways of starting a neonatal pig study before the piglets are placed on the Autosow. These procedures differ based on how critical it is for the researcher to minimize diarrhea. Of course, there can be variations in the duration of time the piglets are left with the sow to nurse and the time taken to prepare the sow before giving birth. The first procedure starts out with the sow delivering her piglets in an unsanitary environment. The piglets would be left with the sow for 1 to 2 days to consume the colostrum needed. Piglets started in this manner will most likely have more diarrhea than the following 2 methods. The second procedure starts with taking the sow to a clean area 4 to 5 days before giving birth and bathing her in an iodine solution. The area in which the sow and her piglets are in would be cleaned regularly. The piglets would remain with the sow for 1 to 2 days in order to receive the colostrum needed. Even though this procedure is more sanitary, it does not mean that the piglets will not have diarrhea. It is a normal phenomenon for piglets to have diarrhea up to 3 weeks of age, hopefully it is reduced using this method. The third procedure again starts with placing the sow in a clean area 4 to 5 days before giving birth and bathing her in an iodine solution. In this procedure the piglets are caught in sterile towels. The adhering membranes are removed and the umbilical cord is cut and the piglet is
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placed in a clean container and taken directly to the clean room which contains the Autosow.
Now you have a colostrum-deprived piglet which has had minimum exposure to the pathogens which cause diarrhea. The piglet in this case should not only have a much reduced frequency of
diarrhea but can be used in studies in which an animal model lacking immunity is required. In all cases a heat source should be provided for the piglets if the room temperature is not at least 30 to 35C (Zoetis and Walls 2003). Additional steps that could be taken in order to reduce the occurrence of diarrhea further would be to take the neonatal pigs either by cesarean section or by hysterectomy as discussed in an article on the use of piglets in immunological studies (Butler et al., 2009). Studies using these procedures will require both highly technical personnel and special facilities and therefore would be more expensive. Pertaining to E. coli derived neonatal diarrhea, two articles (Isaacson et al. 1980; Morgan et al. 1978) were located which reported on vaccinating the sows in the hopes that after colostrum consumption the piglets would benefit and not experience diarrhea and/or death from these pathogens. The piglets did benefit when exposed to the same E. coli strain which possess the same pili (hair-like structures which facilitate colonization and deoxyribonucleic acid transfer) that the sows were vaccinated with, but did not benefit when exposed to a different stain of E. coli. Concerning the number of groups and the number of piglets per group the author of this article will only suggest that all piglet studies have either a vehicle control group or a sow fed control group in addition to a vehicle control group. Current knowledge of the test compound, and the emphasis of the study will be determining factors pertaining to the number of animals used.
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FDA Swine Study: Most neonatal pig studies using the Autosow have one Autosow fed control group, one sow
fed control group and the dosed groups. This was also the case in a study which was done by FDA investigators on trypsin inhibitors at what was the Beltsville Research Facility in Beltsville Maryland (Garthoff et al. 2002a; Garthoff et al. 2002b). Minature swine from FDAs breeding colony were utilized (Hormel-Hanford). Following birth, the piglets were left with the sow for 3 days in order to consume the necessary colostrum. Following 3 days of nursing 37 male piglets (Autosow control group 18, test group 19) were taken to the Autosow where they were weaned and exposed to the test substance until 6 weeks of age. The sow fed control group used 6 male piglets. When weaning was completed, the pigs were removed from the Autosow and were fed a liquid-based diet which contained in the exposed group trypsin inhibitor followed by a regular chow diet. The pigs were sacrificed when they were 39 weeks of age. This study was performed on trypsin inhibitors to study previously reported adverse pancreatic effects in rat studies done mainly on 21-day and 10 week-old animals along with a 2-year study. These studies raised concerns about soy-based infant formula. However, there were questions about extrapolating the rat data to neonatal humans due to the age of the rats used. Also, the rat has cholecystokinin-A receptors predominantly in the pancreas which were shown to mediate pancreatic preneoplastic lesions when azaserine was administered. Humans and pigs on the other
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hand have predominantly cholecystokinin-B receptors . This is another indication that the pig may be a more suitable animal model to assess the potential for human effects (Garthoff et al.
2002a). Swine were chosen because of the developmental stages which can be determined by reproductive and central nervous system development (neonate, infancy, childhood, and
adolescence) of the pig could be more easily correlated to similar stages in humans and, because of the physiological and anatomical similarities between humans and swine in infancy. However, it was noted that the sequence of miniature swine development is some what different than humans. An example was given reporting that miniature swine reach sexual maturity unlike humans long before epiphysial closure occurs (Garthoff et al. 2002a). The neonatal pig trypsin inhibitor study was published in two separate articles, the first one dealt more with the methodology and the second one dealt more with the results. No neoplastic effects on the pancreas were observed in the swine study. This result replicates what was observed in every other species tested with the exception of the rat. The article also reported that the study provided added assurance that there is no increased risk of pancreatic neoplasia, from consuming foods which contain natural trypsin inhibitors (Garthoff et al. 2002b). Neonatal piglet studies will most likely be more expensive than rodent studies. However, since the results of the swine studies will be more relevant in the case of testing new compounds to be used in infant formula this must be taken into consideration. The author of this article believes that the Autosow will help to reduce the cost of maintaining piglets due to the fact that there should be less hands on activity concerning feeding and dosing. Due to the anatomical and physiological similarities
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between pigs and humans and the non-invasiveness of the Autosow feeding method, it would be the authors choice for testing new substances for infant formulas.
Guinea Pig:
The guinea pig is a very interesting and underutilized animal model. Guinea pigs share certain lipoprotein and cholesterol metabolism characteristics with humans. The most notable is that both species carry the majority of plasma cholesterol as low density lipoprotein cholesterol and less as high density lipoprotein cholesterol. Another similarity is a nutritional requirement, in that both humans and guinea pigs require vitamin C in their diet. The third trimester is a time of rapid development for the guinea pig thus, it may only take 2 days for weaning to be complete (Fernandez 2001). Like humans, guinea pigs are also born with a functional immune system by acquiring immunoglobulins in utero (Weaver et al. 1987). The first methodology removed the young from the mother and placed them with a non-lactating surrogate for rearing. (Weaver et al. 1987). The young were gavage fed (with a syringe) up to 8 times a day for a few days (the exact number of days was dependent on when they could feed themselves). The guinea pigs were then fed from a bowl after only a few days of gavage feeding. The next guinea pig study (Lavoie et al. 2004) administered the substances intravenously through indwelling catheters. Unless the species is anatomically and physiologically very similar to humans and the substance is going to be used in this manner this is not an effective paradigm. Due to the lipoprotein similarities between guinea pigs and humans, this species could fill an
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experimental void left by rats and mice when testing high-fat substances.
Ruminates (Lamb): The final animal model reported here is on lambs. The following article (Jones et al. 1993) reported that the lambs were bottle-fed. Catheters were surgically inserted in order to monitor blood pressure. Different substances were injected in order to determine if there would be an effect on blood pressure during feeding. Lambs, of course, can be bottle-fed and therefore can be exposed to infant formulas in a non-invasive manner. However, the practicality of using a ruminate for the toxicological testing of infant formula is questionable due to the differences in anatomy and physiology of the digestive system compared to human infants.
FDA/CDER Nonclinical Guidance Document:
The FDA/CDER (2006) guidance document pertaining to nonclinical studies used to test the safety of pediatric drugs was taken into account. This document is entitled: Guidance for Industry Nonclinical Safety Evaluation of Pediatric Drug Products. The document gives recommendations on the implementation and usage of immature animal models. Below is a summation of the guidance document with some direct quotes including those pertaining to study design. This document was developed for drugs, therefore not every aspect of the document will be relevant to the evaluation of infant formula, but
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useful comparisons can be made.
Pediatric drug safety testing in the past has been supported for the most part by adult clinical studies which have been based on nonclinical adult animal studies. In order to utilize only
adult studies the assumption has to be made that pediatric patients will respond in a similar manner as do adult patients. However, it is clear that some drugs can have different
pharmacological chacteristics in the developing pediatric patient than in the adult patient, and therefore the pediatric patient may react differently to the drug than the adult patient. Juvenile animal studies may be helpful in cases where postnatal developmental parameters have not been adequately tested in reproductive studies and if safety concerns cannot be satisfied clinically. Since certain organ systems continue to develop postnatally there is additional concern regarding how these organ systems may respond to certain pediatric drugs, therefore juvenile animal studies could add to our toxicological knowledge of a given drug better than adult animal studies.
The guidance document states within the Long-Term Exposure in Pediatric Subjects paragraph that: When designing juvenile animal studies, the age of the pediatric population for which the drug is intended is important. Neonates, infants, and older children are at very different developmental stages, and appropriate nonclinical data should support the drugs use in the intended pediatric population. Other considerations are stated under the heading
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Issues to Consider Regarding Juvenile Animal Studies in the guidance document and they are: (1) the intended or likely use of the drug in children; (2) the timing of dosing in
relation to phases of growth and development in pediatric populations and juvenile animals; (3) the potential differences in pharmacological and toxicological profiles between mature and
immature systems; and (4) any established temporal developmental differences in animals relative to pediatric populations. We also recommend that endpoints relevant to identifying target organ toxicity across species be included in the juvenile animal study design. Rats and dogs have been the traditional animals of choice, however there are times when other species may be more appropriate. When choosing a juvenile animal model the similarities and differences of the animal model and humans should be taken into account; these include: metabolism, the stage of organ development and the sensitivity to certain toxicological observations. The guidance document within the paragraph on Species, gives an example of when a particular species may not be appropriate: For example, when drug metabolism in a particular species differs significantly from humans, and alternative species (e.g., minipigs, pigs, monkeys) may be more appropriate for testing. When discussing the route of administration the guidance document reported within the first paragraph under Route of Administration and Dosage Formulation the following: When performing nonclinical studies, the intended clinical route of administration and dosage formulation should be used unless an alternate route of administration and dosage formulation provides greater exposure or is less invasive with adequate exposure. The guidance document also refers to the formulation in a 26
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footnote: We recommend safety evaluations of inactive ingredients be conducted to determine

potential adverse effects in pediatric subjects. The type of testing is dependent on the extent to which this information is already well understood. The dosing protocol should be similar in
frequency, when possible, to that anticipated in a clinical setting. The dose levels administered should demonstrate a clear dose-response with the high dose indicating a clear toxicological effect, the mid-dose demonstrating some toxicity and significant toxicological effects should not be demonstrated in the low dose so that a clear no-observed-adverse-effect level (NOAEL) can be determined. (Of course, this does not pertain to new substances in infant formula in which the hope would be that no adverse toxicological effects would be observed, however if a toxicological effect was observed having it demonstrated in a dose-related manner is preferable for determining a NOAEL.) Important parameters which should be included in the study are: overall growth, organ weights, gross pathology and histopathology, clinical observations, neurobehavioral, reproductive, and any other pertinent parameters. Useful comparisons between drugs and substances new to infant formula can be made particularly when dealing with the study design. Animal models should be chosen that mimic the stage of development of the intended consumer, in this case a neonate or infant. The biological and physiological similarities and differences of the animal model should be taken into account for the substances being administered. The route of administration and the matrix containing the test substance in the test animal model should be as similar as possible to the diet naturally
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consumed by a human infant. The same parameters as for drugs are important when assessing substances new to infant formula, particularly overall growth.
Summary and Conclusion: The optimal diet nutritionally and developmentally for infants is believed to be natural breast milk. For this very reason, producers of infant formula add new
substances to infant formulas in order to more closely mimic natural breast milk. In the past, these substances for the most part were tested using adult animal studies. The reason for this review was to determine whether or not there is an appropriate neonatal animal testing model. Utilizing three different forms of media: IOM (2004) publication, simple YAHOO and Google Scholar searches, and the FDA/CDER (2006) guidance document, neonatal testing
paradigms were examined and evaluated. The literature search clearly indicates that neonatal rats and pigs are the major neonatal animal models utilized at the present time. Neonatal rats and mice are extremely difficult to dose (but can be done with practice), and due to dietary differences and the inability to metabolize a high fat diet in a manner similar to humans; rodent models are inappropriate for testing new substances in infant formula. Neonatal monkeys are a more appropriate model and can consume a high fat diet. However, bottle-feeding is time consuming. In addition, due to the high cost of maintaining primates and the ethical questions raised in sacrificing primates, many researchers would hesitate or are unwilling to use them. Reiterating, the advice of the IOM (2004) publication which stated that the animal model chosen should demonstrate similar metabolic and digestive characteristics compared to the human infant. In addition to the FDA/CDER (2006) guidance document which recommends that the test
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substances be administered to the test animal in a similar matrix as it would be consumed by a human.
The neonatal pig seems to be the most appropriate neonatal model at this time for testing new substances in infant formula for the following reasons. The neonatal pig can be dosed and
fed from the Autosow which is a non-invasive dosing method. Pigs have no problem consuming and metabolizing a high fat diet. Researchers tend to be less hesitant to sacrifice pigs compared to primates. In addition to the anatomical and physiological similarities pertaining to many of the organ systems of both humans and swine particularly the gastrointestinal tract.
Acknowledgements:
The author would like to acknowledge David Hattan, Ph.D. for his assistance and guidance during the process of writing this article.
Declaration of interest: None to declare.
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Neonatal Animal Testing Paradigms Srinivasan M, Aalinkeel R, Song F, Lee B, Laychock SG, Patel MS. 2000. Adaptive changes in insulin secretion by islets from neonatal rats raised on a high-carbohydrate formula. Am J Physiol Endocrinol Metab 279:E1347-E1357.
Srinivasan M, Laychock SG, Hill DJ, Patel MS. 2003. Neonatal nutrition: Metabolic programming of pancreatic islets and obesity. Exp Biol Med 228:15-23. Stegink LD, Brummel MC, Boaz DP, Filer LJ Jr. 1973. Monosodium glutamate metabolism in the neonatal pig: Conversion of administered glutamate into other metabolites in vivo. J Nutr 103:1146-1154. Stegink LD, Reynolds WA, Filer LJ Jr, Pitkin RM, Boaz DP, Brummel MC. 1975. Monosodium glutamate metabolism in the neonatal monkey. Am J Physiol 229:246-250.
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Neonatal Animal Testing Paradigms Weaver LT, Laker MF, Nelson R, Lucas A. 1987. Milk feeding and changes in intestinal permeability and morphology in the newborn. J Pediatr Gastroenterol Nutr 6:351-358. Wedig J, Christian MS, Hoberman A, Diener RM, Thomas-Wedig R. 2002. A study to develop methodology for feeding 24-hour-old neonatal swine for 3 weeks. Int J Toxicol 21:361-370. West DB, Diaz J, Woods SC. 1982. Infant gastrostomy and chronic formula infusion as a technique to overfeed and accelerate weight gain of neonatal rats. J Nutr 112:1339-1343.
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Table 1: Current testing methodologies _____________________________________________________________________________

Species Stage at Initiation Method References _____________________________________________________________________________ Dog Juvenile Diet Oral not specified Monkey Neonate Gavage Bottle-Fed Sawada et al. (2001) Clarke et al. (2001)
Rat
Neonate
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Gavage
E C
T P
Stegink et al. (1975)
Champoux et al. (2002) Jeffrey et al. (2002)
D E
Dorman et al. (2000)
Fukuda et al. (2004) Pan and Chen (2007) Flores et al. (1996) Pollack et al. (1987) Hsiao et al. (2001)
Artificial Rearing
Li et al. (2004) Ismail-Beigi et al. (2006) Wainwright et al. (1999) Srinivasan et al. (2000) Srinivasan et al. (2003) Kinirons et al. (2003) Patel and Srinivasan (2002)
39
Aalinkeel et al. (1999) West, D.B., et al. (1982) Neonatal Animal Testing Paradigms West, J.R. (1993) Flores et al. (1996) Hall (1975)
Potsic et al. (2002) Injected into Jejunum Kraehenbuhl and Campiche (1969) Mice Neonate Gavage
Gavage (Modified)
Pig
Neonate
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C A
Bowl
Artificial Rearing
Intravenous
E C
T P
Eriksson et al. (2002)
Sand et al. (2004)
Viberg et al. (2006)
D E
Butchbach et al. (2007) Beierle et al. (2004) Wykes et al. (1993) Kansagra et al. (2003) Kraehenbuhl and Campiche (1969) Pond et al. (1971) Hrboticky et al. (1990) Craig-Schmidt et al. (1996) Arbuckle et al. (1994) Wedig et al. (2002)
Injected into Jejunum
Bottle-Fed/Feeder Bottle-Fed
Gavage Autosow
Stegink et al. (1973) Lecce (1969) Lecce (1971)
40
Lecce (1975) Lecce and Coalson (1976) Neonatal Animal Testing Paradigms
Table 1: Continued ____________________________________________________________________________

Species Stage at Initiation Method References ____________________________________________________________________________ Lecce et al. (1979) Lecce et al. (1982)
Guinea pig
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Neonate Neonate
C A
E C
T P
Jones et al. (1977)
Rhoads et al. (1990) Rhoads et al. (1992) Gomez et al. (1995) Gomez (1997) Ulshen et al. (1991) Garthoff et al. (2002a) Garthoff et al. (2002b)
D E
Gavage-fed/Bowl Intravenous Bottle-fed/Injected Injected into Jejunum
Weaver et al. (1987) Lavoie et al. (2004) Jones et al. (1993) Kraehenbuhl and Campiche (1969)
Lambs Rabbits
Neonate (1 to 4 weeks)
Gavage
Lee et al. (2000)
The Garthoff et al. (2002a) and (2002b) are on different aspects of the same experiment.
41

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Just Accepted by Toxicology Mechanisms and Methods

Running title: Neonatal Animal Testing Paradigms

Keywords: Autosow, Colostrum, gavage, pup-in-a-cup

Corresponding author Edwin G. Flamm

Neonatal Animal Testing Paradigms

Neonatal Animal Testing Paradigms

Neonatal Animal Testing Paradigms

Results and Discussion:

Neonatal Animal Testing Paradigms

Neonatal Animal Testing Paradigms

Neonatal Animal Testing Paradigms

Insert table 1 here.

Neonatal Animal Testing Paradigms

Neonatal Animal Testing Paradigms

Neonatal Animal Testing Paradigms

Neonatal Animal Testing Paradigms

Artificially Reared Rodents:

Neonatal Animal Testing Paradigms

Neonatal Animal Testing Paradigms

Neonatal Animal Testing Paradigms

Swine (Biology and Physiology):

Neonatal Animal Testing Paradigms

Swine Methodologies other than the Autosow:

of dosing piglets and is an introduction to the next experimental feeding paradigm.

immunoglobulins and therefore are immunocompromised. The piglets acquire immunoglobulins

Neonatal Animal Testing Paradigms

Neonatal Animal Testing Paradigms

FDA/CDER Nonclinical Guidance Document:

useful comparisons can be made.

Neonatal Animal Testing Paradigms

footnote: We recommend safety evaluations of inactive ingredients be conducted to determine

Declaration of interest: None to declare.

Neonatal Animal Testing Paradigms

weaned piglets: liquid vs dry feeding. J Anim Sci 48:1007-1014.

Neonatal Animal Testing Paradigms

Table 1: Current testing methodologies _____________________________________________________________________________

Stegink et al. (1975)

Champoux et al. (2002) Jeffrey et al. (2002)

Dorman et al. (2000)

Eriksson et al. (2002)

Sand et al. (2004)

Viberg et al. (2006)

Injected into Jejunum

Stegink et al. (1973) Lecce (1969) Lecce (1971)

Table 1: Continued ____________________________________________________________________________

Jones et al. (1977)

Gavage-fed/Bowl Intravenous Bottle-fed/Injected Injected into Jejunum

Lee et al. (2000)

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