Breastfeeding and Complementary Feeding

BACKGROUND

Proper infant nutrition promotes healthy growth and development and lowers the risk of disease in later life.

METHODS

This review is based on pertinent articles retrieved by a selective search, including guidelines, meta-analyses, and systematic reviews.

RESULTS

Infants should be exclusively breast-fed until at least the age of 4 months. Infants who are no longer being breast-fed, or no longer exclusively so, should be given commercially available low-protein infant formula containing long-chain polyunsaturated fatty acids. Infants with a family history of allergy should be fed with infant formula based on hydrolyzed protein until complementary feeding begins. Complementary feeding should be initiated no earlier than the beginning of the 5th month and no later than the beginning of the 7th; it should include iron derived from meat, as well as fish once or twice a week. Later initiation of complementary feeding is associated with an increased risk of allergies and is not recommended. Ordinary cow's milk should not be drunk in the first year of life. All infants should be given 2 mg of vitamin K at birth, at 7-10 days, and at 4-6 weeks of age, as well as daily oral supplementation of vitamin D (400-500 IE) and fluoride (0.25 mg).

CONCLUSION

Physicians should advise families about healthful infant nutrition in order to lay the foundation for lifelong good health through a proper diet.

The History of Infant Formula: Quality, Safety, and Standard Methods

Food-related laws and regulations have existed since ancient times. Egyptian scrolls prescribed the labeling needed for certain foods. In ancient Athens, beer and wines were inspected for purity and soundness, and the Romans had a well-organized state food control system to protect consumers from fraud or bad produce. In Europe during the Middle Ages, individual countries passed laws concerning the quality and safety of eggs, sausages, cheese, beer, wine, and bread; some of these laws still exist today. But more modern dietary guidelines and food regulations have their origins in the latter half of the 19th century when the first general food laws were adopted and basic food control systems were implemented to monitor compliance. Around this time, science and food chemistry began to provide the tools to determine "purity" of food based primarily on chemical composition and to determine whether it had been adulterated in any way. Since the key chemical components of mammalian milk were first understood, infant formulas have steadily advanced in complexity as manufacturers attempt to close the compositional gap with human breast milk. To verify these compositional innovations and ensure product quality and safety, infant formula has become one of the most regulated foods in the world. The present paper examines the historical development of nutritional alternatives to breastfeeding, focusing on efforts undertaken to ensure the quality and safety from antiquity to present day. The impact of commercial infant formulas on global regulations is addressed, along with the resulting need for harmonized, fit-for-purpose, voluntary consensus standard methods.

Long-chain polyunsaturated fatty acids and the preterm infant: a case study in developmentally sensitive nutrient needs in the United States

The vast majority of infant formulas in the United States contain the long-chain polyunsaturated fatty acids (PUFAs) docosahexaenoic acid (22:6n-3) and arachidonic acid (20:4n-6), which were first permitted by the US Food and Drug Administration in 2001. As a scientific case study, preclinical animal studies of these nutrients definitively influenced the design and interpretation of human clinical studies. Early studies were tied to the availability of test substances, and in hindsight suggest re-evaluation of the essential fatty acid concept in light of the totality of available evidence. Research in the 1950s established the essentiality of n-6 PUFAs for skin integrity; however, widespread recognition of the essentiality of n-3 PUFAs came decades later despite compelling evidence of their significance. Barriers to an understanding of the essentiality of n-3 PUFAs were as follows: 1) their role is in neural function, which is measured only with difficulty compared with skin lesions and growth faltering that are apparent for n-6 PUFAs; 2) the experimental use of vegetable oils as PUFA sources that contain the inefficiently used C18 PUFAs rather than the operative C20 and C22 PUFAs; 3) the shift from reliance on high-quality animal studies to define mechanisms that established the required nutrients in the first part of the 20th century to inherently challenging human studies. Advances in nutrition of premature infants require the best practices and opinions available, taking into account the totality of preclinical and clinical evidence.

[The system of the quality control and the safety of baby food, the prospects of its development]

In the article there is considered the substantiation of raise demands to the chemical composition of children’s food and indices of their safety, with taking into account the immaturity of metabolic and physiological processes and limitations of “depot” of nutrients in babies. Based on research results of leading experts in the field of children’s nutritiology and according to the recommendations of the Codex Alimentarius of the Commission of FAO/WHO, ESPGHAN Committee on Nutrition, the EFSA recommendations and EUDirectives there were specified requirements for the ingredient composition, content of essential components and indices of the nutritional value of substitutes for human milk and functional products for the nutrition of infants of the first year of life. There are shown stages of the development of the Russian system of hygienic requirements for baby food, and the direction of its harmonization with international and European standards, particularly for substitutes for human milk and products of dietary therapeutic and dietary preventive nutrition for babies. There are considered aspects of the introduction ofproducts and weaning food dishes into the food ration of infants. There is presented the classification ofproducts of children’s food and the assortment of each group of weaning foods. There is provided the modern legislative framework in the field of the quality and safety for infant nutrition. There was shown the difference between domestic legislation and regulatory framework of the EurAsEC Customs Union of the European countries in the field offood products safety for children older three years. There are presented proposals on the creation of the single regulatory base within the framework of the EurAsEC Customs Union for control the quality and safety of all the baby foods.

The European Food Safety Authority recommendation for polyunsaturated fatty acid composition of infant formula overrules breast milk, puts infants at risk, and should be revised

The European Food Safety Authority (EFSA) has concluded from a limited review of the literature that although docosahexaenoic acid (DHA) is required for infant formula, arachidonic acid is not required "even in the presence of DHA" (EFSA Journal, 12 (2014) 3760). This flawed opinion is grounded in human trials which tested functionality of DHA in neural outcomes and included arachidonic acid ostensibly to support growth. The EFSA report mistakes a nutrient ubiquitous in the diets of newborn infants, through breast milk and with wide-ranging health and neurodevelopmental effects, for an optional drug targeted to a particular outcome that is properly excluded when no benefit is found for that particular outcome. Arachidonic acid has very different biological functions compared to DHA, for example, arachidonic acid has unique functions in the vasculature and in specific aspects of immunity. Indeed, the overwhelming majority of trials include both DHA and arachidonic acid, and test development specific to DHA such as neural and visual development. DHA suppresses membrane arachidonic acid concentrations and its function. An infant formula with DHA and no arachidonic acid runs the risk of cardio and cerebrovascular morbidity and even mortality through suppression of the favorable oxylipin derivatives of arachidonic acid. The EFSA recommendation overruling breast milk composition should be revised forthwith, otherwise being unsafe, ungrounded in most of the evidence, and risking lifelong disability.

[Expert consensus on the nutritional aspects of initial and follow-on infant formulas]

INTRODUCTION

Infant feeding in the first months/years of life affects the health in the short and long term. Breastfeeding is the perfect food due to its many benefits. However, when breastfeeding is not possible, infant formulas are the best alternative. The aim of this study is to define the role of the supplemented formulas in infant nutrition using the opinion of a panel of experts in infant gastroenterology and nutrition.

MATERIAL AND METHODS

A survey, using 62 items, stratified into 5 blocks, was performed by 48 panelists using the Delphi method to achieve a professional criteria consensus on nutritional aspects of infant formulas.

RESULTS

A consensus was reached in 64.6% of the items, with a non-unified agreement being established as regards the nutritional aspects of infant formulas, and their influence in body and brain development and immune maturity.

CONCLUSIONS

According to the experts surveyed, there is consensus as regards the suitable composition of lipids, lactose, calcium, vitamin D, and prebiotics in infant formulas, for a correct cerebral, immune and somatic development. There was no consensus on the not yet well-defined subjects, such as nutritional quality of proteins, use of thickeners, taurine supplementation, probiotic, and symbiotic aspects. More studies are necessary to confirm these subjects.

Application of evidence on probiotics, prebiotics and synbiotics by food industry: a descriptive study

BACKGROUND

This study assessed how the food industry applies the knowledge and evidence gained from synbiotics, probiotics or prebiotics research in infants, on the general paediatric population. This study also explored: what happens after the clinical trials using infant formula are completed, data is published or remains unpublished; the effectiveness and type of medium the formula manufacturers use to educate consumers on probiotic, prebiotic or synbiotic infant formula.

FINDINGS

This was a descriptive study (a survey) that used a structured questionnaire. All listed companies that manufacture and / or market food products with added probiotics, prebiotics or synbiotics for infants were identified and invited to participate. People responsible for research and development were invited to participate in the survey. A letter of invitation was sent to selected participants and if they expressed willingness to take part in the study, a questionnaire with a written consent form was sent. Descriptive statistics and associations between categorical variables were to be tested using a Chi-square test, a p < 0.05 was statistically significant.A total of 25 major infant formulas, baby food manufacturers were identified, invited to participate in the survey. No company was willing to participate in the survey for different reasons: failure to take any action 5 (20%), decision to participate indefinitely delayed 2 (8%), sensitivity of requested information 3 (12%), company does not conduct clinical trials 1 (4%), company declined without further information 4 (16%), erroneous contact information 6 (24%), refusal by receptionists to forward telephone calls to appropriate staff 3 (12%), language barrier 3 (12%), company no longer agrees to market research 1 (4%).

CONCLUSION

Due to a poor response rate in this study, no conclusion could be drawn on how the food industry applies evidence gained through probiotics, prebiotics or synbiotics research on infants for the benefit of the general paediatric population. More information and greater transparency is needed from the infant formula manufacturers on how they apply the evidence gained from the research on probiotics, prebiotics and synbiotics on infants.

Current good manufacturing practices, quality control procedures, quality factors, notification requirements, and records and reports, for infant formula. Final rule

The Food and Drug Administration (FDA or we) is issuing a final rule that adopts, with some modifications, the interim final rule (IFR) entitled "Current Good Manufacturing Practices, Quality Control Procedures, Quality Factors, Notification Requirements, and Records and Reports, for Infant Formula'' (February 10, 2014). This final rule affirms the IFR's changes to FDA's regulations and provides additional modifications and clarifications. The final rule also responds to certain comments submitted in response to the request for comments in the IFR.

Improving the New Zealand dairy industry's contribution to local and global wellbeing: the case of infant formula exports

On narrow economic measures of wellbeing, New Zealand's dairy industry is a huge success. Infant formula, in particular, is New Zealand's 'export superstar'. However, using a broader wellbeing lens, there is some public disquiet about environmental, human and animal wellbeing associated with the dairy industry. This article questions whether New Zealand's dairy industry is also undermining global 'best practice' infant feeding. It argues that while there is support for increased trade and exports, there are few voices promoting global infant health and that discussion is needed on this issue by the New Zealand public health community.

Nutrient-enriched formula versus standard term formula for preterm infants following hospital discharge

BACKGROUND

Preterm infants are often growth-restricted at hospital discharge. Feeding infants after hospital discharge with nutrient-enriched formula rather than standard term formula might facilitate "catch-up" growth and improve development.

OBJECTIVES

To determine the effect of feeding nutrient-enriched formula compared with standard term formula on growth and development for preterm infants following hospital discharge.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011, Issue 4), MEDLINE, EMBASE, and CINAHL (to September 2011), conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared the effect of feeding preterm infants following hospital discharge with nutrient-enriched formula (post-discharge formula or preterm formula) compared with standard term formula.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

We found 15 eligible trials in which a total of 1128 preterm infants participated. The trials were of variable methodological quality with lack of allocation concealment and incomplete follow-up in some trials being the major potential sources of bias. The trials (N = 10) that compared feeding infants with "post-discharge formula" (energy density about 74 kcal/100 ml) versus standard term formula (about 67 kcal/100 ml) did not find consistent evidence of effects on growth parameters up to 12 to 18 months corrected age. The trials (N = 5) that compared feeding with "preterm formula" (about 80 kcal/100 ml) versus term formula found some evidence of higher rates of growth through infancy: weighted mean differences at 12 to 18 months corrected age about 500 g in weight, 5 to10 mm in length, and 5 mm in head circumference. Few trials assessed neurodevelopmental outcomes and these did not detect any statistically significant differences in developmental indices at 18 months corrected age. There are not yet any data on growth or development through later childhood.

AUTHORS' CONCLUSIONS

Current recommendations to prescribe "post-discharge formula" for preterm infants following hospital discharge are not supported by the available evidence. Some limited evidence exists that feeding preterm infants following hospital discharge with "preterm formula" (which is generally only available for in-hospital use) may increase growth rates up to 18 months corrected age.

The effect of neutral and acidic oligosaccharides on stool viscosity, stool frequency and stool pH in preterm infants

AIM

To determine the effect of neutral oligosaccharides [small-chain galacto-oligosaccharides/long-chain fructo-oligosaccharides (scGOS/lcFOS)] in combination with acidic oligosaccharides (pAOS) on stool viscosity, stool frequency and stool pH in preterm infants.

METHODS

In this explorative RCT, preterm infants with gestational age <32 weeks and/or birth weight <1500 g received enteral supplementation with scGOS/lcFOS/pAOS or placebo (maltodextrin) between days 3 and 30 of life. Stool samples were collected at day 30 after birth.

RESULTS

In total, 113 infants were included. Baseline and nutritional characteristics were not different between both groups. Stool viscosity at day 30 was lower in the prebiotics group (16.8N) (3.9-67.8) compared with the placebo group (26.3N) (1.3-148.0) (p = 0.03; 95% CI -0.80 to 0.03). There was a trend towards higher stool frequency in the prebiotics group (3.1 ± 0.8) compared with the placebo group (2.8 ± 0.7) (p = 0.15; 95% CI -0.08 to 0.52). Stool pH at day 30 was lower in the in the prebiotics group (5.9 ± 0.6) compared with the placebo group (6.2 ± 0.3) (p = 0.009; 95% CI 0.08 to 0.53).

CONCLUSIONS

Enteral supplementation of a prebiotic mixture consisting of neutral (scGOS/lcFOS) and acidic oligosaccharides (pAOS) decreases stool viscosity and stool pH with a trend towards increased stool frequency in preterm infants. The inclusion of pAOS in a formula containing a mixture of scGOS/lcFOS does not add specific advantages to the formula in terms of stool viscosity, frequency, pH as well as feeding tolerance.

Preparation and characterization of standard reference material 1849 infant/adult nutritional formula

Standard Reference Material (SRM) 1849 Infant/Adult Nutritional Formula has been issued by the National Institute of Standards and Technology (NIST) as a replacement for SRM 1846 Infant Formula, issued in 1996. Extraction characteristics of SRM 1846 have changed over time, as have NIST's analytical capabilities. While certified mass fraction values were provided for five constituents in SRM 1846 (four vitamins plus iodine), certified mass fraction values for 43 constituents are provided in SRM 1849 (fatty acids, elements, and vitamins) and reference mass fraction values are provided for an additional 43 constituents including amino acids and nucleotides, making it the most extensively characterized food-matrix SRM available from NIST.

Which is the ideal target for preterm growth?

In the last two decades the improved survival of very low birth weight (VLBW) and extremely low birth weight (ELBW) infants has underscored the problem of postnatal growth failure of these subjects. Notwithstanding the evident improvements in the general management of these infants during the hospital stay, most of them acquire a significant extrauterine growth restriction (EUGR). Frequent illnesses, medical and surgical therapies, feeding intolerance and, most of all, inadequacy of nutrient deliveries are responsible for the great part of this growth failure. However other factors, such as genetics, prenatal environment, hormones and metabolic pathways may contribute to growth impairment, that my persist until adulthood. Most of VLBW infants exhibit some catch-up growth, especially in late childhood and adolescence, but they generally remain smaller than their term peers. However, the most worrying aspect is related to the detrimental effect of growth impairment, especially if involving head circumference, on neurodevelopment outcomes of these infants. The endocrine, metabolic and cardiovascular long term consequences of under- and/or hypernutrition of VLBW infants are still to be elucidated. In the meantime, the efforts of the neonatotolgists should be focused on improving, how much as possible, the early nutrient management of these infants, allowing them to reach an adequate growth rate (at least 18-20 g/kg/d), then avoiding the need of a late unphysiological catch-up growth.

[The contribution of enteral nutrition in the premature infant]

In recent years, improvements in obstetrical and neonatal care have significantly improved survival in preterm and, particularily, the very low birth weight infant. Several studies stress the importance of timely and adequate nutrition in these high-risk infants on a short- and long-term. Presently, there is little consensus among the neonatologists concerning the optimal way to initiate, advance or maintain enteral feeding in preterm Infants. The preferred food for premature infants is fortified milk from the infant's own mother or,alternatively, formula designed for premature infants. The recent guidelines proposed by ESPGHAN Committee on Nutrition provide minimal and maximal levels of intake for individual macro- and micro-nutrients.

Formulas providing adequate pantothenic acid, vitamin D, manganese, iron and vitamin A for infants fed with mother's milk (aged 6-11 months) according to the Japanese Dietary Reference Intakes prepared by the Ministry of Health, Labour and Welfare (2005 edition)

Weaning formulas served in hospitals and care facilities in Japan should conform to dietary reference intakes (DRIs). We examined whether the DRI for breastfed infants aged 6-11 months can be satisfied in dietary practice, with a particular focus on the fulfilment rates for vitamins, minerals, trace elements and electrolytes in weaning formulas containing energy and protein at levels either greater than or equal to the DRIs, as well as on the dietary profiles of weaning formulas to achieve the DRI for every nutrient. The results showed that no weaning formulas examined in this study fulfilled the DRI for pantothenic acid (5 mg), vitamin D (4 microg), manganese (1.2 mg) or iron (5.5 mg). Furthermore, their vitamin A content exceeded the DRI (350 microg RE). The discrepancy between the guidelines and actual dietary practice is probably because of the fact that the estimated reference values poorly reflect the actual dietary intake in the target population; for example, the pantothenic acid and manganese DRIs for breastfed infants aged 6-11 months were set based on the breast milk intake of younger infants (0-5 months) in combination with the breast milk contents. Our results suggest that dietary guidance for infants should include information to promote proper intakes of vitamins A and D, and iron by reducing the amount of vitamin A-rich foods and utilizing dietary vitamin D and iron supplements including government-approved specified health foods.

Prophylaxis of vitamin D deficiency--Polish Recommendations 2009

Adequate vitamin D intake and its status are important not only for bone health and Ca-P metabolism, but for optimal function of many organs and tissues throughout the body. Due to documented changes in dietary habits and physical activity levels, both observed in growing children and adults, the prevalence of vitamin D insufficiency is continuously increasing. National consultants and experts in the field have established some Polish recommendations for prophylactic vitamin D supplementation in infants, toddlers, children, and adolescents as well as in adults, including pregnant and lactating women basing on a review of current literature.