Food For Thought: Halal Formula, Kosher Medication, Vegan Supplements?

Halal formula? Chances are that you, as a parent or a health professional, have never heard of it, or have even given its existence a thought. Still, you might be interested in knowing what ingredients a newborn’s formula milk or medication contains. As midwives, we should be capable of giving correct information to parents with specific dietary wishes for their child. This is however not always that easy. Many ingredients are highly processed, and manufacturers and labels often don’t give clear information on the source of ingredients and how they have been manufactured. This can make it hard for (future) parents to make informed choices and poses a challenge for health professionals who want to give reliable information.


​​From Halal to Vegan

There is an increasing group of critical consumers, who all have their own motives for keeping certain dietary restrictions. Some are religiously motivated, as is the case for Muslims, Jews and Hindus. Others adhere to certain food philosophies or ideologies, as is often the case with vegetarians and vegans, while still others have medical reasons, such as intolerances or allergies. Furthermore, within both secular and religious dietary laws a lot of variation and differing interpretations exist, and on top of that there are individual preferences, which doesn’t make it easy to provide tailor-made information.


From Pork to Product

​​The challenge is that regular food or medication can contain all sort of components derived from animals that have not been processed according to specific prescriptions (religious or otherwise). During processing, characteristics and properties often fundamentally change and substances end up in products as (in)active ingredients in an entirely different form. This opens the debate whether after this transformation, the substances should be considered as still essentially the same as before. Another question is how to make an informed choice when nature and origin of the primary ingredients are not revealed?


​​​​In many routinely administered medication and supplements, active ingredients from an animal source may be found, such as conjugated oestrogens, heparin, insulin (though this is becoming rarer and rarer), glucosamine, heme iron supplements and calcium tablets. Inactive ingredients that people may not be aware of include stearic acids (which also may have been used in the production process), ethanol (alcohol) and gelatin.


Now let’s look at a few examples you might come across in the perinatal period.


During Pregnancy


A household name on the bedside table of pregnant women is folic acid, the synthetic form of vitamin B9. It is supposed to prevent common birth defects like neural tube defects (spina bifida) and is generally recommended to be taken from one month before conception up to three months pregnancy. Folic acid is sold over the counter and comes in many different brands and forms (often combined in special multi-vitamin tablets for pregnancy). The exact source of its ingredients varies quite a bit, as folic acid can be derived from vegetable, fungal or animal sources. For consumers, it can be hard to determine the origin of a specific brand of folic acid, as it is often not mentioned on the package.



Not a few pregnant women struggle with morning sickness. A commonly prescribed medication against it is Primperan (metoclopramide). Often, these tablets contain magnesium stearate, an inactive substance serving as a filler or a binding agent. Magnesium stearate is usually derived from pork, chicken, beef, fish, milk or butter but it can also be derived from vegetable sources. Generally, the packaging will not tell you whether animal fat was used, unless it is explicitly mentioned that the tablets are suitable for vegans.


Urinary tract infections are also among those common challenges many women are facing. During pregnancy, a pro-active approach is recommended because of possible maternal and fetal complications. In this respect, an often prescribed broad spectrum antibiotics is amoxicillin. One of the inactive ingredients you will often find in amoxicillin capsules is gelatin, which is an animal protein that is typically gained by boiling collagenous parts (such as bones) of pigs and cattle.


Mothers with Rhesus negative blood can be exposed to Rhesus positive blood of their fetus during pregnancy, especially in the third trimester. In order to prevent an immune response of the mother from negatively affecting the foetus, anti-D immunoglobulin is often routinely administered. Few mothers know that anti-D is made from blood plasma of screened donors and also contains glycine. This is an amino acid gained through protein hydrolysis, and it is often hard to find out what the source of the protein used is.


For the Newborns


Although in most cases breastfeeding is the preferred mode of feeding a newborn, there can be quite some reasons for parents to choose (or switch to) formula feeding. Finding a fitting formula that is digested well is often a process of trial and error. For Muslims, Jews, Hindus and vegetarians, formula milk can contain an unwanted surprise. Many formula brands use, among other ingredients, nucleotide, an enzyme not seldom extracted from a pig’s belly fat.In general, some powdered infant milks are halal approved, but most ready to feed brands of milk are not available in a halal-approved version. You can find an overview of kosher and halal formula milk here.


​​​​Breastfeeding also does not entirely escape the discussion, as is proven by a debate on the acceptability of donor breast milk that emerged during the setting up of a human milk bank in Turkey. According to Islamic law, sharing human milk creates a ‘milk kinship’ between the families of the donor and recipient, which for instance includes certain marriage prohibitions. Knowing the donor is therefore important to the parents involved. They also won’t appreciate a mix of milk of different mothers. Besides, some think that receiving breast milk of non-muslim mothers will have an impact on a child’s religious choices later in life, while others worry more about the food non-muslim donors may have eaten. There seem to be more than a few different stances in this discussion, but in general, as a NICU nurse or midwife it’s good to be aware when offering human milk to prematures that some parents may have reservations because of religious or other reasons.


Without wanting to heat up the current debates on vaccines or take a stance in it, I think future parents should be informed about the ingredients of vaccines their newborn will receive. Many people don’t get near vaccine package inserts or simply don’t read them and are therefore often unaware that a vaccine may contain preservatives, adjuvants, stabilizers, residuals of cell culture material, inactivating ingredients and antibiotics of which some are of human or animal origin. Check here for an overview.


Conclusion

​​

Given the challenges described above, I initially set out to compile a list of essential products for different groups who try to keep dietary restrictions during pregnancy and childbirth. This soon proved impossible within a reasonable amount of time. This in itself illustrates the problem that the critical consumer faces in our time: there is a great lack of transparency and of generally acknowledged, authoritative sources. ​​

​​Of course there exist websites, inspecting and (self-declared) testing authorities and certificates within specific groups, for example among the Jews, Muslims and vegans. However, they are not easily found, they don’t provide a complete overview of all different sort of products and not all products are available everywhere. It is also difficult to get a quick but thorough view on what synthetic alternatives might already be available and applicable.


One can question how much space for choice there is or should be in life-threatening and emergency situations. For instance, a premature baby might need parenteral (intravenous) feeding, among which a lipid emulsion, in order to survive. Demanding choice in this setting might not favour the immediate interest of the baby.


In general, patients from whatever background, have a right to all the information they need to make truly informed decisions about the treatment they receive. The small exploration made for this blog illustrates that this is currently not the case. Although patient information leaflets often state the medical and nutritional ingredients, they fail to mention their initial sources and the process used to derive them. With the number of critical consumers and patients on the rise, however, the call for transparency will not diminish.


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Resources

A.a. (2014). What is Halal in Medical Terms? See: https://halaltreatments.com/2014/08/26/what-is-halal-in-medical-terms/

Blech, Z.Y. (s.d.). The Kosher Formula. See: http://www.star-k.org/articles/articles/1148/the-kosher-formula/

Centers for Disease Control (2017). Vaccine Excipient & Media Summary Excipients Included in U.S. Vaccines, by Vaccine. See:

https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf

Crawley, H. & Westland, S. (2017). Infant Milks in the UK: A Practical Guide for Health Professionals. First Steps Nutrition Trust. See: http://www.firststepsnutrition.org/pdfs/Infant_Milks_February2017.pdf

First Steps Nutrition Trust. (2016). A Simple Guide to Infant Milks. See: http://www.firststepsnutrition.org/pdfs/Infant_milks_a_simple_guide_NIreland_Feb16.pdf

Ogden, J. (2016). Religious constraints on prescribing medication. Prescriber December. See: http://onlinelibrary.wiley.com/doi/10.1002/psb.1524/pdf Star-K (s.d.). Kosher Medicine List (only for US). See: http://www.star-k.org/resources_medicine

Photo Credits

Photo 1: CCBY Francois Bester, Flickr. See: https://flic.kr/p/4iSjY6

Photo 3: CCBY World Bank Photo Collection, Flickr. See: https://flic.kr/p/dnyySh

Photo 4: CCBY Phalinn Ooi, Flickr. See: https://flic.kr/p/fxoCuZ

Photo 5: CCBY European Parliament, Flickr. See: https://flic.kr/p/9strtj

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