Effect of folic acid supplementation on small-for-gestational-age infants born at term

Bioactive Compounds in Infant Formula and Their Effects on Infant Nutrition and Health: A Systematic Literature Review

Infant formulas are an alternative to replace or supplement human milk when breastfeeding is not possible. The knowledge of human milk's bioactive compounds and their beneficial effects has attracted the interest of researchers in the field of infant nutrition, as well as researchers of technology and food sciences that seek to improve the nutritional characteristics of infant formulas. Several scientific studies evaluate the optimization of infant formula composition. The bioactive compound inclusion has been used to upgrade the quality and nutrition of infant formulas. In this context, the purpose of this systematic literature review is to assess the scientific evidence of bioactive compounds present in infant formulas (α-lactalbumin, lactoferrin, taurine, milk fat globule membrane, folates, polyamines, long-chain polyunsaturated fatty acids, prebiotics, and probiotics) and their effects on infant nutrition and health. Through previously determined criteria, studies published in the last fifteen years from five different databases were included to identify the advances in the optimization of infant formula composition. Over the last few years, there has been optimization of the infant formula composition, not only to increase the similarities in their content of macro and micronutrients but also to include novel bioactive ingredients with potential health benefits for infants. Although the infant food industry has advanced in the last years, there is no consensus on whether novel bioactive ingredients added to infant formulas have the same functional effects as the compounds found in human milk. Thus, further studies about the impact of bioactive compounds in infant nutrition are fundamental to infant health.

Antimicrobial and micronutrient interventions for the management of infants under 6 months of age identified with severe malnutrition: a literature review

BACKGROUND

Infants under 6 months (U6M) contribute a significant proportion of the burden and mortality of severe malnutrition globally. Evidence of underlying aetiology in this population is sparse, but it is known that the group includes ex-preterm and low birthweight (LBW) infants. They represent a unique population given their dependence on breastmilk or a safe, secure alternative. Nutrition agencies and health providers struggle to make programming decisions on which interventions should be provided to this group based upon the 2013 WHO Guidelines for the 'Management of Severe Acute Malnutrition in Infants and Young Children' since there are no published interventional trial data focussed on this population. Interim guidance for this group might be informed by evidence of safety and efficacy in adjacent population groups.

METHODOLOGY

A narrative literature review was performed of systematic reviews, meta-analyses and randomised controlled trials of antimicrobial and micronutrient interventions (antibiotics, deworming, vitamin A, vitamin D, iron, zinc, folic acid and oral rehydration solution (ORS) for malnutrition) across the population groups of low birthweight/preterm infants, infants under 6 months, infants and children over 6 months with acute malnutrition or through supplementation to breastfeeding mothers. Outcomes of interest were safety and efficacy, in terms of mortality and morbidity.

RESULTS

Ninety-four articles were identified for inclusion within this review. None of these studied interventions exclusively in severely malnourished infants U6M. 64% reported on the safety of studied interventions. Significant heterogeneity was identified in definitions of study populations, interventions provided, and outcomes studied. The evidence for efficacy and safety across population groups is reviewed and presented for the interventions listed.

CONCLUSIONS

The direct evidence base for medical interventions for severely malnourished infants U6M is sparse. Our review identifies a specific need for accurate micronutrient profiling and interventional studies of micronutrients and oral fluid management of diarrhoea amongst infants U6M meeting anthropometric criteria for severe malnutrition. Indirect evidence presented in this review may help shape interim policy and programming decisions as well as the future research agenda for the management of infants U6M identified as malnourished.

Effect of folate supplementation on folate status and health outcomes in infants, children and adolescents: a systematic review

The aim of this systematic review was to collect all available randomized controlled trials on the effect of folate supplementation on folate status and health outcomes within the paediatric age group. The method included a structured search strategy on MEDLINE, Embase and Cochrane databases, with formal inclusion/exclusion criteria and data extraction procedure. We included 26 studies. We conclude that both serum and erythrocyte folate values reflect folate intake; however, serum folate reacts more rapidly to folate intake than erythrocyte folate. As to health outcomes, we found no evidence indicating that additional intake of folate can influence haematological parameters in non-anaemic paediatric patients. We were unable to find evidence of a favourable effect of folate supplementation on the growth of infants. However, the limited data available suggest that supplementing the diet of low-birth-weight infants with folic acid may moderate the rapid fall of serum and red cell folate in the first months of life.

The nutritional requirements of infants. Towards EU alignment of reference values: the EURRECA network

This paper presents a review of the current knowledge regarding the macro- and micronutrient requirements of infants and discusses issues related to these requirements during the first year of life. The paper also reviews the current reference values used in European countries and the methodological approaches used to derive them by a sample of seven European and international authoritative committees from which background scientific reports are available. Throughout the paper, the main issues contributing to disparities in micronutrient reference values for infants are highlighted. The identification of these issues in relation to the specific physiological aspects of infants is important for informing future initiatives aimed at providing standardized approaches to overcome variability of micronutrient reference values across Europe for this age group.

Vitamin requirements for term infants: considerations for infant formulae

OBJECTIVE

To provide the informed health professional with an up to date evaluation of the current thinking regarding requirements for vitamins in infant feeds. ESTABLISHING CRITERIA FOR ADEQUACY: Vitamin adequacy in the neonate is currently defined in terms of circulating levels of a vitamin or of the activity of a vitamin dependent enzyme in the erythrocytes. Although these measurements have their value there is a need to develop biochemical, physiological or clinical markers of well defined specific function. For some vitamins there is a risk of deleterious effects of very high intakes: risk of toxicity needs to be taken into consideration when making recommendations for inclusion in infant formulae. BREAST MILK AS THE 'GOLD STANDARD': Breast milk concentrations of vitamins have been used as the criteria of adequate intake by neonates. This may not always be justified. Greater consideration needs to be given to differences in bioavailability of vitamins from breast milk compared with formula feeds, of the influence of season, and of stage of lactation, on the stated composition.

EXPERIMENTAL APPROACHES

Animal studies have provided limited information regarding effects of different levels of intakes on current status indices in the neonatal period. There are few reports of randomized controlled studies into the effects of different levels of vitamins and these rely heavily on biochemical criteria of adequacy.

RECENT DEVELOPMENTS

The inclusion of beta-carotene into formula feeds for premature babies is an issue of current interest. What is the justification for this? Are there potential benefits for the term infant? Riboflavin deficiency in the period around weaning may affect the normal structural and functional development of the gastrointestinal tract; some of these effects may be permanent. RESEARCH TO BE DONE: A greater understanding of the absorption and metabolism of vitamins during infancy is required in order to help establish dietary requirements. The relative bioavailability of vitamins in human milk and formulae needs to be investigated. Criteria for vitamin adequacy should be extended to include measures of function. Information regarding the conversion factor from tryptophan to niacin in infancy would allow us to set niacin requirements with greater confidence. There is a particular lack of information about concentrations of biotin and pantothenic acid in breast milk and the relative biochemical status of infants receiving breast milk and formulae. Benefits of including beta-carotene into infant formulae need to be evaluated. The role of individual micronutrients in the structural and functional development of the gastrointestinal tract should be explored.

Níveis de ácido fólico sérico em lactentes eutróficos, alimentados com leite materno, leite de vaca ou fórmula modificada

OBJETIVO: Verificar os níveis de ácido fólico em três grupos de lactentes e comparar os valores encontrados; avaliar a necessidade de suplementação dessa vitamina aos quatro meses, quando as reservas teciduais são escassas e as fontes dietéticas pobres em folatos, em um período no qual a alimentação é exclusivamente láctea. MÉTODOS: Foram analisados os níveis de ácido fólico sérico, obtidos pelo método de radioimunoensaio, em 120 lactentes eutróficos, aos quatro meses, com alimentação láctea exclusiva, sendo 40 com aleitamento materno, 40 com leite de vaca pasteurizado e fervido e 40 com fórmula láctea industrializada e enriquecida com ácido fólico. RESULTADOS: Os níveis de ácido fólico sérico nos lactentes alimentados exclusivamente com leite de vaca pasteurizado e fervido foram significativamente menores do que os dos lactentes alimentados com leite materno e os alimentados com fórmula láctea modificada, enriquecida com folatos. Estes dois últimos grupos não mostraram diferenças entre si. CONCLUSÕES: O estudo ressalta a necessidade de suplementação de ácido fólico nos lactentes aos quatro meses alimentados exclusivamente com leite de vaca. A pasteurização e a fervura do leite de vaca, habitualmente utilizadas, levam à deficiência dessa vitamina, tão importante na nutrição humana.

Plasma folate levels in preterm infants, with and without a 1 mg daily folate supplement

One hundred and four preterm infants were studied during the first few months of life in the Special Care Baby Unit of Addenbrooke's Hospital, Cambridge, United Kingdom. Previously, it had been the daily practice within the Unit to give a 1 mg oral supplement of folate (in the form of pteroylglutamic acid), once the infants had commenced full enteral feeding. At least one blood sample was obtained from 70 infants before oral folate supplementation was started. In these, the plasma folate levels fell progressively from a median value of 45 micrograms/l to a median of 12 micrograms/l, by the 2nd-3rd week of life. Once started on the oral supplement, 83 of the infants provided at least one blood sample. The plasma folate level of these infants rose immediately to a median value of 300 micrograms/l and a maximum of 1000 micrograms/l. Within individuals, these plasma folate levels decreased progressively following the introduction of the supplement, despite continuing daily supplementation. In a typical baby this decrease appeared to be explained by an increase in body-size, i.e. dilution of the folate into a larger pool. The implications of this level of supplementation are discussed, and in the light of our observations we suggest that daily supplementation in the range, 0.05-0.2 mg folate may be preferable for well preterm infants.