Infant formula supplementation with long-chain polyunsaturated fatty acids has no effect on Bayley developmental scores at 18 months of age--IPD meta-analysis of 4 large clinical trials

Macronutrient intake during infancy and neurodevelopment in preschool children from the EDEN mother-child cohort

BACKGROUND

Although the deleterious effect of micronutrient deficiency at sensitive periods on neurodevelopment is well established, the potential influence of macronutrient intake on early life neurodevelopment of healthy term infants has been seldomly studied. We aimed to explore whether macronutrient intake at 12 months was related to neurodevelopmental scores in preschool children.

METHODS

Analyses were based on data from the EDEN mother-child cohort. Macronutrient intake was assessed by 3-day food records at 12 months of age. Neurodevelopment was assessed at 3 years using the French version of the Ages and Stages Questionnaire (ASQ) (n = 914), and at 5-6 years, using the French version of the Wechsler Preschool and Primary Scale of Intelligence-Third Edition (n = 785). An association between macronutrient intake and neurodevelopmental scores were analysed by multivariable linear regression for 3-year Full Score ASQ or 5-6-year intelligence quotient scores and multivariable logistic regression for 3-year ASQ subdomains.

RESULTS

Macronutrient intake in infancy was not associated with neurodevelopmental scores in preschool children. No association was found between PUFA intake and overall neurodevelopmental scores, after accounting for multiple testing.

CONCLUSION

In the present study, macronutrient intake at one year did not appear to influence the child's cognitive ability at 3 and 5-6 years. Further studies are needed to clarify the relationship between early fatty acid intake and neurodevelopment.

Dietary Reference Intakes based on chronic disease endpoints: outcomes from a case study workshop for omega 3's EPA and DHA

Given the focus on developing Dietary Reference Intakes (DRIs) based on chronic disease risk reduction and recent research for omega-3 long chain PUFA since the last DRI review, the Canadian Nutrition Society convened a panel of stakeholders for a 1-day workshop in late 2019. Attendees discussed the new NASEM guidelines for establishing DRI values based on chronic disease risk endpoints and the strength of current evidence for EPA and DHA as it relates to the new guidelines. Novelty: Summarizes evidence and expert opinions regarding the potential for reviewing DRI values for EPA and DHA and cardiovascular disease risk and early development.

Effects of LC-PUFA supply via complementary food on infant development-a food based intervention (RCT) embedded in a total diet concept

BACKGROUND

With the introduction of complementary food, long-chain PUFA (LC-PUFA) supply usually decreases during the second 6 months of life. However, the need for LC-PUFA is still high for infant's rapid development. The aim of this randomized, controlled intervention trial was to examine the effects of an increased n-3 (LC-)PUFA supply using alternative complementary foods on infants' visual and cognitive development.

METHODS

Mother-child dyads of term infants were recruited in maternity hospitals and randomly assigned to one of three study groups, which all were fed according to the German dietary schedule for infant nutrition. Intervention group IG-R (n = 54) received jars of complementary food with rapeseed oil, IG-F (n = 48) jars with oily fish twice a week and the control group (CG, n = 58) the same jars as IG-R with corn oil instead of rapeseed oil during the intervention period (5th-10th month of age). The outcome measures were latencies of FVEP, Bayley's mental developmental index (MDI), and psychomotor developmental index (PDI).

RESULTS

At 10 months of age, there were no significant differences in latencies of FVEP, Bayley's MDI, or in PDI index between the intervention and control groups.

CONCLUSIONS

Fish and rapeseed oil used as (LC-)PUFA sources provided with complementary feeding embedded in a structured infant diet did not affect visual or cognitive development of term infants.

The Long-Term Effects of Dietary Nutrient Intakes during the First 2 Years of Life in Healthy Infants from Developed Countries: An Umbrella Review

The role of both qualitative and quantitative early nutrient intakes on later health has been suggested for decades and supported by observational studies on humans, mainly preterm and low-birth-weight infants, and animal models. However, to date, no comprehensive review has been conducted to evaluate the full impact of nutritional variables on healthy full-term infants. This umbrella review considers meta-analyses and systematic reviews on the health effects of different nutritional exposures or interventions in the first 2 y of life of healthy full-term infants in developed countries. The systematic reviews and meta-analyses published by March 2018 in MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews were included. The following outcomes were considered: growth and obesity, cardiovascular disease, neurodevelopment, allergy and autoimmunity, infections, and malignancy. Breastfeeding and complementary feeding were considered separately and analyzed by means of their differences in delivering heterogeneous food-related variables. The resulting data on the long-term effect of early nutritional differences in healthy full-term infants were found to be inconclusive. Only breastfeeding has a beneficial effect, which is nevertheless slight and limited to just a few outcome measures, whereas the type and duration required to be effective are still unclear. As regards the complementary feeding period, no clear effects of different dietary interventions emerge in terms of health outcomes. Available evidence on the health effects of differences in early nutrition in healthy full-term infants still remains largely inconclusive.

Beyond the Bayley: Neurocognitive Assessments of Development During Infancy and Toddlerhood

The use of global, standardized instruments is conventional among clinicians and researchers interested in assessing neurocognitive development. Exclusively relying on these tests for evaluating effects may underestimate or miss specific effects on early cognition. The goal of this review is to identify alternative measures for possible inclusion in future clinical trials and interventions evaluating early neurocognitive development. The domains included for consideration are attention, memory, executive function, language, and socioemotional development. Although domain-based tests are limited, as psychometric properties have not yet been well-established, this review includes tasks and paradigms that have been reliably used across various developmental psychology laboratories.

Neurodevelopmental outcome of nutritional intervention in newborn infants at risk of neurodevelopmental impairment: the Dolphin neonatal double-blind randomized controlled trial

AIM

To investigate whether neonates at risk for neurodevelopmental impairment have improved neurodevelopment after docosahexaenoic acid, choline, and uridine-5-monophosphate supplementation versus controls.

METHOD

Recruitment was from UK neonatal units. Eligible for inclusion were infants born at less than 31 weeks' gestation with a weight less than the ninth centile; infants born at less than 31 weeks' gestation with a grade II or higher intraventricular haemorrhage/preterm white matter injury; infants born between 31 weeks' and 40 weeks' gestation plus 28 days with a grade II or higher intraventricular haemorrhage/preterm white matter injury, moderate or severe hypoxic-ischaemic encephalopathy, or defined neuroimaging abnormalities. Treatment/control supplementation was for 2 years (double-blind, randomized, controlled design). Infants were stratified according to sex, gestation, and brain injury severity. Primary outcome was cognitive composite score (CCS) of the Bayley Scales of Infant Development, Third Edition (Bayley-III at 24mo). Secondary outcomes were language composite score (LCS) of the Bayley-III, motor composite score (MCS) of the Bayley-III, and Vineland Adaptive Behaviour Scales, Second Edition (VABS-II) score.

RESULTS

Sixty-two neonates were recruited, 59 were randomized (34 males, 25 females). Fifty-three started supplementation. Most families found supplementation acceptable. The treatment group CCS-Bayley-III scores were non-significantly higher than controls (mean score difference at 24mo: 9.0; 95% confidence interval -0.2 to 18.2). Language and VABS-II scores, but not motor score, were non-significantly higher in the treatment group.

INTERPRETATION

Most families found supplementation feasible. Improved neurodevelopmental outcomes in the treatment group were not statistically significant. A larger multicentre trial exploration is warranted.

WHAT THIS PAPER ADDS

Dietary supplementation of neonates at risk of neurodevelopmental impairment is feasible. No statistically significant neurodevelopmental advantages were identified for the treatment group compared to controls. Treatment group cognitive and language advantage are of a clinically meaningful magnitude.

Long chain polyunsaturated fatty acid supplementation in infants born at term

BACKGROUND

The long chain polyunsaturated fatty acids (LCPUFA) docosahexaenoic acid (DHA) and arachidonic acid (AA) are considered essential for maturation of the developing brain, retina and other organs in newborn infants. Standard infant milk formulae are not supplemented with LCPUFA; they contain only alpha-linolenic acid and linoleic acid, from which formula-fed infants must synthesise their own DHA and AA, respectively. Over the past few years, some manufacturers have added LCPUFA to formula milk and have marketed these products as providing an advantage for the overall development of full-term infants.

OBJECTIVES

To assess whether supplementation of formula milk with LCPUFA is both safe and beneficial for full-term infants, while focusing on effects on visual function, neurodevelopment and physical growth.

SEARCH METHODS

Two review authors independently searched the Cochrane Central Register of Controlled Trials (CENTRAL; December 2016), MEDLINE (Ovid, 1966 to December 2016), Embase (Ovid, 1980 to December 2016), the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1980 to December 2016) and abstracts of the Pediatric Academic Societies (2000 to 2016). We applied no language restrictions.

SELECTION CRITERIA

We reviewed all randomised controlled trials (RCTs) evaluating effects of LCPUFA supplemented versus non-supplemented formula milk on visual function, neurodevelopment and physical growth. We did not include trials reporting only biochemical outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. We assessed risk of bias of included studies using the guidelines of the Cochrane Neonatal Review Group. When appropriate, we conducted meta-analysis to determine a pooled estimate of effect.

MAIN RESULTS

We identified 31 RCTs and included 15 of these in the review (N = 1889).Nine studies assessed visual acuity, six of which used visual evoked potentials (VEP), two Teller cards and one both. Four studies reported beneficial effects, and the remaining five did not. Meta-analysis of three RCTs showed significant benefit for sweep VEP acuity at 12 months (log of the minimum angle of resolution (logMAR)) (mean difference (MD) -0.15, 95% confidence interval (CI) -0.17 to -0.13; I² = 0; three trials; N = 244), but meta-analysis of three other RCTs showed no benefit for visual acuity measured with Teller cards at 12 months (cycles/degree) (MD -0.01, 95% CI -0.12 to 0.11; I² = 0; three trials; N = 256). GRADE analysis for the outcome of visual acuity indicated that the overall quality of evidence was low.Eleven studies measured neurodevelopmental outcomes at or before two years. Nine studies used Bayley Scales of Infant Development, version II (BSID-II), and only two of these studies reported beneficial effects. Meta-analysis revealed no significant differences between LCPUFA and placebo groups in BSID Mental Developmental Index (MDI) scores at 18 months (MD 0.06, 95% CI -2.01 to 2.14; I² = 75%; four trials; N = 661) and no significant differences in BSID Psychomotor Development Index (PDI) scores at 18 months (MD 0.69, 95% CI -0.78 to 2.16; I² = 61%; four trials; N = 661). Results showed no significant differences between the two groups in BSID-II scores at one year and two years of age. One study reported better novelty preference measured by the Fagan Infant Test at nine months. Another study reported better problem solving at 10 months. One study used the Brunet and Lezine test to assess the developmental quotient and found no beneficial effects. Follow-up of some infants in different studies at three, six and nine years of age revealed no beneficial effects of supplementation. GRADE analysis of these outcomes indicated that the overall quality of evidence was low.Thirteen studies measured physical growth; none found beneficial or harmful effects of supplementation. Meta-analysis of five RCTs showed that the supplemented group had lower weight (z scores) at one year of age (MD -0.23, 95% CI -0.40 to -0.06; I² = 83%; N = 521) and that the two groups showed no significant differences with respect to length and head circumference (z scores). Meta-analysis at 18 months and at two years revealed no significant differences between the two groups with respect to weight (kg), length (cm) and head circumference (cm). GRADE analysis of these outcomes indicated that the overall quality of evidence was low.

AUTHORS' CONCLUSIONS

Most of the included RCTs reported no beneficial effects or harms of LCPUFA supplementation on neurodevelopmental outcomes of formula-fed full-term infants and no consistent beneficial effects on visual acuity. Routine supplementation of full-term infant milk formula with LCPUFA cannot be recommended at this time.

Longchain polyunsaturated fatty acid supplementation in preterm infants

BACKGROUND

Controversy exists over whether longchain polyunsaturated fatty acids (LCPUFA) are essential nutrients for preterm infants because they may not be able to synthesise sufficient amounts of LCPUFA to meet the needs of the developing brain and retina.

OBJECTIVES

To assess whether supplementation of formula milk with LCPUFA is safe and of benefit to preterm infants. The main areas of interest were the effects of supplementation on the visual function, development and growth of preterm infants.

SEARCH METHODS

Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2) in the Cochrane Library (searched 28 February 2016), MEDLINE Ovid (1966 to 28 February 2016), Embase Ovid (1980 to 28 February 2016), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1980 to 28 February 2016), MEDLINE In Process & Other Non-indexed Citations (1966 to 28 February 2016) and by checking reference lists of articles and conference proceedings. We also searched ClinicalTrials.gov (13 April 2016). No language restrictions were applied.

SELECTION CRITERIA

All randomised trials evaluating the effect of LCPUFA-supplemented formula in enterally-fed preterm infants (compared with standard formula) on visual development, neurodevelopment and physical growth. Trials reporting only biochemical outcomes were not included.

DATA COLLECTION AND ANALYSIS

All authors assessed eligibility and trial quality, two authors extracted data separately. Study authors were contacted for additional information.

MAIN RESULTS

Seventeen trials involving 2260 preterm infants were included in the review. The risk of bias varied across the included trials with 10 studies having low risk of bias in a majority of the domains. The median gestational age (GA) in the included trials was 30 weeks and median birth weight (BW) was 1300 g. The median concentration of docosahexaenoic acid (DHA) was 0.33% (range: 0.15% to 1%) and arachidonic acid (AA) 0.37% (range: 0.02% to 0.84%). Visual acuity Visual acuity over the first year was measured by Teller or Lea acuity cards in eight studies, by visual evoked potential (VEP) in six studies and by electroretinogram (ERG) in two studies. Most studies found no significant differences in visual acuity between supplemented and control infants. The form of data presentation and the varying assessment methods precluded the use of meta-analysis. A GRADE analysis for this outcome indicated that the overall quality of evidence was low. Neurodevelopment Three out of seven studies reported some benefit of LCPUFA on neurodevelopment at different postnatal ages. Meta-analysis of four studies evaluating Bayley Scales of Infant Development at 12 months (N = 364) showed no significant effect of supplementation (Mental Development Index (MDI): MD 0.96, 95% CI -1.42 to 3.34; P = 0.43; I² = 71% - Psychomotor DeveIopment Index (PDI): MD 0.23, 95% CI -2.77 to 3.22; P = 0.88; I² = 81%). Furthermore, three studies at 18 months (N = 494) also revealed no significant effect of LCPUFA on neurodevelopment (MDI: MD 2.40, 95% CI -0.33 to 5.12; P = 0.08; I² = 0% - PDI: MD 0.74, 95% CI -1.90 to 3.37; P = 0.58; I² = 54%). A GRADE analysis for these outcomes indicated that the overall quality of evidence was low. Physical growth Four out of 15 studies reported benefits of LCPUFA on growth of supplemented infants at different postmenstrual ages (PMAs), whereas two trials suggested that LCPUFA-supplemented infants grow less well. One trial reported mild reductions in length and weight z scores at 18 months. Meta-analysis of five studies (N = 297) showed increased weight and length at two months post-term in supplemented infants (Weight: MD 0.21, 95% CI 0.08 to 0.33; P = 0.0010; I² = 69% - Length: MD 0.47, 95% CI 0.00 to 0.94; P = 0.05; I² = 0%). Meta-analysis of four studies at a corrected age of 12 months (N = 271) showed no significant effect of supplementation on growth outcomes (Weight: MD -0.10, 95% CI -0.31 to 0.12; P = 0.34; I² = 65% - Length: MD 0.25; 95% CI -0.33 to 0.84; P = 0.40; I² = 71% - Head circumference: MD -0.15, 95% CI -0.53 to 0.23; P = 0.45; I² = 0%). No significant effect of LCPUFA on weight, length or head circumference was observed on meta-analysis of two studies (n = 396 infants) at 18 months (Weight: MD -0.14, 95% CI -0.39 to 0.10; P = 0.26; I² = 66% - Length: MD -0.28, 95% CI -0.91 to 0.35; P = 0.38; I² = 90% - Head circumference: MD -0.18, 95% CI -0.53 to 0.18; P = 0.32; I² = 0%). A GRADE analysis for this outcome indicated that the overall quality of evidence was low.

AUTHORS' CONCLUSIONS

Infants enrolled in the trials were relatively mature and healthy preterm infants. Assessment schedule and methodology, dose and source of supplementation and fatty acid composition of the control formula varied between trials. On pooling of results, no clear long-term benefits or harms were demonstrated for preterm infants receiving LCPUFA-supplemented formula.

The Effect of Supplementation of Long-Chain Polyunsaturated Fatty Acids During Lactation on Neurodevelopmental Outcomes of Preterm Infant From Infancy to School Age: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Long-chain polyunsaturated fatty acids, especially docosahexaenoic acid, have been suggested as a nutrition factor affecting visual and neurobehavioral development of preterm infants. Several randomized controlled trials (RCTs) have investigated the effect of supplementation of long-chain polyunsaturated fatty acids on preterm infants. We conducted a systematic review and meta-analysis to examine the efficacy of long-chain polyunsaturated fatty acid supplementation of formula or breast milk on the neurodevelopment outcomes of preterm infants.

METHODS

Two authors searched PubMed and Cochrane Library (CENTRAL) for RCTs assessing efficacy of long-chain polyunsaturated fatty acids supplementation on the neurobehavioral and development outcomes of preterm infant. Human RCTs which supplemented long-chain polyunsaturated fatty acids during lactation and assessed neurodevelopment were included. The quality of each RCT was assessed, and the results of eligible trials were included in the systematic review and meta-analysis.

RESULTS

We included 11 RCTs with 2272 total participants. Methodologic limitations existed to some extent in most RCTs that were included. Because the age of the participants from different trails was not the same, different scales and indexes had been assessed from different RCTs. Our meta-analysis indicated a significant effect of long-chain polyunsaturated fatty acids supplementation on the neurodevelopment of preterm infants assessed by the Mental Development Index of the Bayley Scales at one to three years of age versus the control groups.

CONCLUSION

Analysis of our consolidated data indicates that long-chain fatty acid supplementation results in a significant improvement in the neurodevelopment of preterm infants as assessed by the Mental Development Index at one to three years of age. The available evidence suggests that long-chain polyunsaturated fatty acid supplementation during lactation may accelerate the pace of neurodevelopment in preterm infants, although their final developmental outcome may be unchanged.

Early postnatal docosahexaenoic acid levels and improved preterm brain development

BACKGROUND

Preterm birth has a dramatic impact on polyunsaturated fatty acid exposures for the developing brain. This study examined the association between postnatal fatty acid levels and measures of brain injury and development, as well as outcomes.

METHODS

A cohort of 60 preterm newborns (24-32 wk gestational age) was assessed using early and near-term magnetic resonance imaging (MRI) studies. Red blood cell fatty acid composition was analyzed coordinated with each scan. Outcome at a mean of 33 mo corrected age was assessed using the Bayley Scales of Infant Development, 3rd edition.

RESULTS

Adjusting for confounders, a 1% increase in postnatal docosahexaenoic acid (DHA) levels at early MRI was associated with 4.3-fold decreased odds of intraventricular hemorrhage, but was not associated with white matter injury or cerebellar haemorrhage. Higher DHA and lower linoleic acid (LA) levels at early MRI were associated with lower diffusivity in white matter tracts and corresponding improved developmental scores in follow-up.

CONCLUSION

Higher DHA and lower LA levels in the first few weeks of life are associated with decreased intraventricular haemorrhage, improved microstructural brain development, and improved outcomes in preterm born children. Early and possibly antenatal interventions in high-risk pregnancies need to be studied for potential benefits in preterm developmental outcomes.

The Essentiality of Arachidonic Acid in Infant Development

Arachidonic acid (ARA, 20:4n-6) is an n-6 polyunsaturated 20-carbon fatty acid formed by the biosynthesis from linoleic acid (LA, 18:2n-6). This review considers the essential role that ARA plays in infant development. ARA is always present in human milk at a relatively fixed level and is accumulated in tissues throughout the body where it serves several important functions. Without the provision of preformed ARA in human milk or infant formula the growing infant cannot maintain ARA levels from synthetic pathways alone that are sufficient to meet metabolic demand. During late infancy and early childhood the amount of dietary ARA provided by solid foods is low. ARA serves as a precursor to leukotrienes, prostaglandins, and thromboxanes, collectively known as eicosanoids which are important for immunity and immune response. There is strong evidence based on animal and human studies that ARA is critical for infant growth, brain development, and health. These studies also demonstrate the importance of balancing the amounts of ARA and DHA as too much DHA may suppress the benefits provided by ARA. Both ARA and DHA have been added to infant formulas and follow-on formulas for more than two decades. The amounts and ratios of ARA and DHA needed in infant formula are discussed based on an in depth review of the available scientific evidence.

Economic impact of breast-feeding-associated improvements of childhood cognitive development, based on data from the ALSPAC

The aim of this study was to assess the economic benefits of improved cognitive development related to being breast-fed. Breast-feeding rates were assessed in the Avon Longitudinal Study of Parents and Children. Educational attainment was assessed at age 16 years with higher attainment defined as gaining five General Certificate of Secondary Education (GCSE) passes at a high grade. The economic benefit of being breast-fed was calculated in a decision model using a child's educational attainment and the corresponding expected value of average income in later life. There was a positive association between being breast-fed and achieving higher educational attainment, which remained significant, after adjustment for possible confounders: being breast-fed <6 months yielded an OR of 1·30 (95 % CI 1·13, 1·51) and for ≥6 months yielded an OR of 1·72 (95 % CI 1·46, 2·05), compared with never breast-fed children. On the basis of UK income statistics, the present value of lifetime gross income was calculated to be £67 500 higher for children achieving 5 high-grade GCSE passes compared with not achieving this. Therefore, the economic benefit of being breast-fed <6 months would be £4208 and that for ≥6 months would be £8799/child. The model shows that the increased educational attainment associated with being breast-fed has a positive economic benefit for society, even from small improvements in breast-feeding rates. Within a total UK birth cohort of 800 000/year an increase by 1 % in breast-feeding rates would be worth >£33·6 million over the working life of the cohort. Therefore, breast-feeding promotion is likely to be highly cost-effective and policymakers should take this into consideration.

A meta-analysis of nutrition interventions on mental development of children under-two in low- and middle-income countries

Interventions to improve nutritional status of young children in low- and middle-income countries (LMIC) may have the added benefit of improving their mental and motor development. This meta-analysis updates and goes beyond previous ones by answering two important questions: (1) do prenatal and postnatal nutritional inputs improve mental development, and (2) are effects on mental development associated with two theoretically interesting mediators namely physical growth and motor development? The meta-analysis of articles on Medline, PsycINFO, Global Health and Embase was limited to randomized trials in LMICs, with mental development of children from birth to age two years as an outcome. The initial yield of 2689 studies was reduced to 33; 12 received a global quality rating of strong. Of the 10 prenatal and 23 postnatal nutrition interventions, the majority used zinc, iron/folic acid, vitamin A or multiple micronutrients, with a few evaluating macronutrients. The weighted mean effect size, Cohen's d (95% CI) for prenatal and postnatal nutrition interventions on mental development was 0.042 (-0.0084, 0.092) and 0.076 (0.019, 0.13), respectively. Postnatal supplements consisting of macronutrients yielded an effect size d (95% CI) of 0.14 (0.0067, 0.27), multiple micronutrients 0.082 (-0.012, 0.18) and single micronutrients 0.058 (-0.0015, 0.12). Motor development, but not growth status, effect sizes were significantly associated with mental development in postnatal interventions. In summary, nutrition interventions had small effects on mental development. Future studies might have greater effect if they addressed macronutrient deficiencies combined with child stimulation and hygiene and sanitation interventions.

Infant formula and neurocognitive outcomes: impact of study end-point selection

OBJECTIVES

Assessing validity and reliability of end points used in docosahexanoic and arachidonic acids (DHA and ARA) infant formula supplementation trials as an example for addressing the impact of end-point selection and critical need for well-defined, reliable and validated clinical outcome assessments for neurocognitive assessment in neonates and infants.

STUDY DESIGN

We searched eight electronic databases and reviewed all randomized, controlled human trials using DHA/ARA supplements with neurodevelopment clinical outcomes. We systematically evaluated the validity and reliability of end-point measures based on the criteria for studying nutritional additives recommended by the Institute of Medicine, criteria described in the Food and Drug Administration guidance for clinical outcome assessment, development and literature review.

RESULTS

We identified 29 articles that met the selection criteria. The end points that were used for neurodevelopment measures in 23 out of 29 original short-term studies included the Bayley Scale of Infant Development (BSID)-I and -II (n=12), Brunet-Lezine test (n=2), videotape infant's movements (n=1), record time to milestones including sitting, crawling, standing and walking (n=1), problem-solving test (n=2), brainstem auditory-evoked potential (n=1), Touwen examination (n=1), Fagan test of infant intelligence (n=2) and visual habituation protocol (n=1). None of these end points have a long-term predictive property for neurocognitive assessment. Compared with standard infant formula, the beneficial effects of DHA/ARA supplementation on neurodevelopment were reported in 2 out of 12 studies using BSID vs 8 out of 11 studies using other end-point measures. In addition, 6 out of 29 long-term follow-up studies used the end points including Stanford-Binet IQ test (n=1), Wechsler Preschool and Primary Scale of Intelligence (n=4) and Bracken Basic Concept Scale (n=1), which are generally scales of intellectual ability and typically do not change substantively in the short term. None of these long-term follow-up studies demonstrated beneficial effects of DHA/ARA supplementation on neurodevelopment.

CONCLUSION

The choice of end-point measures affects the outcomes of DHA/ARA-supplemented infant formula trials. Available data are currently inadequate to conclude that DHA/ARA supplementation has a clinically meaningful beneficial effect upon neurological development. Although BSID is validated to assess early developmental delays, it is not designed to predict long-term neurocognitive outcome. A well-defined, valid and reliable clinical outcome assessment that measures neurocognitive function in neonates and infants is essential to provide the scientific evidence required for future clinical trials.

Optimising nutrition to improve growth and reduce neurodisabilities in neonates at risk of neurological impairment, and children with suspected or confirmed cerebral palsy

Background

Neurological impairment is a common sequelae of perinatal brain injury. Plasticity of the developing brain is due to a rich substrate of developing neurones, synaptic elements and extracellular matrix. Interventions supporting this inherent capacity for plasticity may improve the developmental outcome of infants following brain injury. Nutritional supplementation with combination docosahexaenoic acid, uridine and choline has been shown to increase synaptic elements, dendritic density and neurotransmitter release in rodents, improving performance on cognitive tests. It remains elusive whether such specific ‘neurotrophic’ supplementation enhances brain plasticity and repair after perinatal brain injury.

Methods/Design

This is a two year double-blind, randomised placebo controlled study with two cohorts to investigate whether nutritional intervention with a neurotrophic dietary supplement improves growth and neurodevelopmental outcomes in neonates at significant risk of neurological impairment (the D1 cohort), and infants with suspected or confirmed cerebral palsy (the D2 cohort).

120 children will be randomised to receive dietetic and nutritional intervention, and either active supplement or placebo. Eligible D1 neonates are those born <30⁺⁶ weeks gestation with weight <9^th centile, ≤30⁺⁶ weeks gestation and Grade II, III or IV Intra-Ventricular Haemorrhage or periventricular white matter injury, or those born at 31-40⁺²⁸ weeks gestation, with Sarnat grade I or II or III Hypoxic Ischaemic Encephalopathy or neuroimaging changes compatible with perinatal brain injury. Eligible D2 infants are those aged 1-18 months with a suspected or confirmed clinical diagnosis of cerebral palsy. The primary outcome measure is composite cognitive score on the Bayley Scales of Infant and Toddler Development III at 24 months. Secondary outcomes include visuobehavioural and visual neurophysiological assessments, and growth parameters including weight, height, and head circumference.

Discussion

This is the first study to supplement neonates and infants with perinatal brain injury with the combination of factors required for healthy brain development, throughout the period of maximal brain growth. A further study strength is the comprehensive range of outcome measures employed. If beneficial, supplementation with brain phosphatide precursors could improve the quality of life of thousands of children with perinatal brain injury.

Trial registration

Current Controlled trials: ISRCTN39264076 (registration assigned 09/11/2012), ISRCTN15239951 (registration assigned 23/04/2010).

Global health and development in early childhood

Health and nutritional risks co-occur in the lives of children under the age of 2 years who live in developing countries. We review evidence showing how these risks, in addition to inadequate psychosocial stimulation, prevent children from developing expected cognitive and language abilities. A systematic review and meta-analysis of 21 interventions aimed at enhancing stimulation and 18 interventions that provided better nutrition--all conducted since 2000--revealed that stimulation had a medium effect size of 0.42 and 0.47 on cognitive and language development, respectively, whereas nutrition by itself had a small effect size of 0.09. The implementation processes of these interventions are described and compared. A number of unresolved issues are outlined and discussed, including ways to maximize parental health behavior change, assess mediators that account for intervention effects, and expand the assessment of young children's brain functions that underlie language and cognition and are affected by nutrition and stimulation.

Nutritional and immunological considerations relevant to infant nutrition

Optimal nutrition during infancy is critical not only to support the dramatic growth and development that takes place during the first 12 months following birth but also for establishing a healthy immune response throughout childhood and across the life span. The normative standards for infant feeding and nutrition are breast-feeding and human breast milk. However, in cases in which human breast milk is not available, infant formula is substituted. Providing optimal patient care that results in the best clinical outcomes depends on understanding the unique attributes of the 3 main sources of nutrition for newborns. This state of the science review provides an update on the macronutrient and immunological content of human milk, donor milk, and infant formula and highlights the relevance of these sources of infant nutrition on the development of immune system.

Does docosahexaenoic acid supplementation in term infants enhance neurocognitive functioning in infancy?

The proposal that dietary docosahexaenoic acid (DHA) enhances neurocognitive functioning in term infants is controversial. Theoretical evidence, laboratory research and human epidemiological studies have convincingly demonstrated that DHA deficiency can negatively impact neurocognitive development. However, the results from randomized controlled trials (RCTs) of DHA supplementation in human term-born infants have been inconsistent. This article will (i) discuss the role of DHA in the human diet, (ii) explore the physiological mechanisms by which DHA plausibly influences neurocognitive capacity, and (iii) seek to characterize the optimal intake of DHA during infancy for neurocognitive functioning, based on existing research that has been undertaken in developed countries (specifically, within Australia). The major observational studies and RCTs that have examined dietary DHA in human infants and animals are presented, and we consider suggestions that DHA requirements vary across individuals according to genetic profile. It is important that the current evidence concerning DHA supplementation is carefully evaluated so that appropriate recommendations can be made and future directions of research can be strategically planned.

Long-term effects of LCPUFA supplementation on childhood cognitive outcomes

BACKGROUND

The effect of long-chain polyunsaturated fatty acid (LCPUFA) intake on cognitive development is controversial. Most randomized trials have assessed cognition at 18 mo, although significant development of cognitive abilities (early executive function) emerge later.

OBJECTIVE

The objective was to evaluate cognition beyond 18 mo and longitudinal cognitive change from 18 mo to 6 y in children who were fed variable amounts of docosahexaenoic acid (0.32%, 0.64%, and 0.96% of total fatty acids) and arachidonic acid (ARA; 0.64%) compared with children who were not fed LCPUFA as infants.

DESIGN

Eighty-one children (19 placebo, 62 LCPUFA) who participated in a double-blind, randomized trial of LCPUFA supplementation as infants were re-enrolled at 18 mo and tested every 6 mo until 6 y on age-appropriate standardized and specific cognitive tests.

RESULTS

LCPUFA supplementation did not influence performance on standardized tests of language and performance at 18 mo; however, significant positive effects were observed from 3 to 5 y on rule-learning and inhibition tasks, the Peabody Picture Vocabulary Test at 5 y, and the Weschler Primary Preschool Scales of Intelligence at 6 y. Effects of LCPUFAs were not found on tasks of spatial memory, simple inhibition, or advanced problem solving.

CONCLUSIONS

The data from this relatively small trial suggest that, although the effects of LCPUFAs may not always be evident on standardized developmental tasks at 18 mo, significant effects may emerge later on more specific or fine-grained tasks. The results imply that studies of nutrition and cognitive development should be powered to continue through early childhood. This parent trial was registered at clinicaltrials.gov as NCT00266825.

Maternal dietary fat intake in association with autism spectrum disorders

Our goal in this study was to determine whether maternal fat intake before or during pregnancy was associated with risk of autism spectrum disorder (ASD) in the offspring. Our primary analysis included 317 mothers who reported a child with ASD and 17,728 comparison mothers from the Nurses' Health Study II (index births in 1991-2007). Dietary information was collected prospectively through a validated food frequency questionnaire. Binomial regression was used to estimate crude and adjusted risk ratios. Maternal intake of linoleic acid was significantly inversely associated with ASD risk in offspring, corresponding to a 34% reduction in risk in the highest versus lowest quartiles of intake. Mothers in the lowest 5% of ω-3 fatty acid intake had a significant increase in offspring ASD risk as compared with the remaining distribution (risk ratio = 1.53, 95% confidence interval: 1.00, 2.32); this association was also seen in the subgroup of women (86 cases and 5,798 noncases) for whom dietary information during pregnancy was available (risk ratio = 2.42, 95% confidence interval: 1.19, 4.91). Thus, variations in intake of polyunsaturated fats within the range commonly observed among US women could affect fetal brain development and ASD risk. Because the number of women with diet assessed during pregnancy was small, however, these results should be interpreted cautiously.

DHA supplementation: current implications in pregnancy and childhood

Dietary supplementation with ω-3 long chain fatty acids including docosahexaenoic acid (DHA) has increased in popularity in recent years and adequate DHA supplementation during pregnancy and early childhood is of clinical importance. Some evidence has been built for the neuro-cognitive benefits of supplementation with long chain polyunsaturated fatty acids (LCPUFA) such as DHA during pregnancy; however, recent data indicate that the anti-inflammatory properties may be of at least equal significance. Adequate DHA availability in the fetus/infant optimizes brain and retinal maturation in part by influencing neurotransmitter pathways. The anti-inflammatory properties of LCPUFA are largely mediated through modulation of signaling either directly through binding to receptors or through changes in lipid raft formation and receptor presentation. Our goal is to review the current findings on DHA supplementation, specifically in pregnancy and infant neurodevelopment, as a pharmacologic agent with both preventative and therapeutic value. Given the overall benefits of DHA, maternal and infant supplementation may improve neurological outcomes especially in vulernable populations. However, optimal composition of the supplement and dosing and treatment strategies still need to be determined to lend support for routine supplementation.

Omega 3 fatty acids on child growth, visual acuity and neurodevelopment

The aim of this review is to evaluate the effects of omega-3 long chain polyunsaturated fatty acids (n-3 LCPUFA) supplementation in pregnant and lactating women and infants during postnatal life, on the visual acuity, psychomotor development, mental performance and growth of infants and children. Eighteen publications (11 sets of randomized control clinical trial [RCTs]) assessed the effects of the n-3 LCPUFA supplementation duringpregnancyon neurodevelopment and growth, in the same subjects at different time points; 4 publications (2 data sets from RCTs) addressed physiological responses to n-3 LCPUFA supplementation duringpregnancy & lactationand 5 publications (3 data sets from RCTs) exclusively duringlactation. Some of these studies showed beneficial effects of docosahexaenoic acid (DHA) supplementation during pregnancy and/or lactation especially on visual acuity outcomes and some on long-term neurodevelopment; a few, showed positive effects on growth. There were also 15 RCTs involving term infants who received infant formula supplemented with DHA, which met our selection criteria. Many of these studies claimed a beneficial effect of such supplementation on visual, neural, or developmental outcomes and no effects on growth. Although new well designed and conducted studies are being published, evidence from RCTs does not demonstrate still a clear and consistent benefit of n-3 LCPUFA supplementation during pregnancy and/or lactation on term infants growth, neurodevelopment and visual acuity. These results should be interpreted with caution due to methodological limitations of the included studies.

Effects of high-dose fish oil supplementation during early infancy on neurodevelopment and language: a randomised controlled trial

n-3 Long-chain PUFA (LC-PUFA) intake during infancy is important for neurodevelopment; however, previous studies of n-3 LC-PUFA supplementation have been inconclusive possibly due to an insufficient dose and limited methods of assessment. The present study aimed to evaluate the effects of direct supplementation with high-dose fish oil (FO) on infant neurodevelopmental outcomes and language. In the present randomised, double-blind, placebo-controlled trial, 420 healthy term infants were assigned to receive a DHA-enriched FO supplement (containing at least 250 mg DHA/d and 60 mg EPA/d) or a placebo (olive oil) from birth to 6 months. Assessment occurred at 18 months via the Bayley Scales of Infant and Toddler Development (3rd edition; BSID-III) and the Child Behavior Checklist. Language assessment occurred at 12 and 18 months via the Macarthur–Bates Communicative Development Inventory. The FO group had significantly higher erythrocyte DHA (P = 0·03) and plasma phospholipid DHA (P = 0·01) levels at 6 months of age relative to placebo. In a small subset analysis (about 40 % of the total population), children in the FO group had significantly higher percentile ranks of both later developing gestures at 12 and 18 months (P = 0·007; P = 0·002, respectively) and the total number of gestures (P = 0·023; P = 0·006, respectively). There was no significant difference between the groups in the standard or composite scores of the BSID-III. The results suggest that improved postnatal n-3 LC-PUFA intake in the first 6 months of life using high-dose infant FO supplementation was not beneficial to global infant neurodevelopment. However, some indication of benefits to early communicative development was observed.

Long-chain polyunsaturated fatty acid supplementation in infants born at term

BACKGROUND

The n-3 and n-6 fatty acids linolenic acid and linoleic acid are precursors of the n-3 and n-6 long chain fatty acids (LCPUFA). Infant formula has historically only contained the precursor fatty acids. Over the last few years, some manufacturers have added LCPUFA to formulae and marketed them as providing an advantage for the development of term infants.

OBJECTIVES

To assess whether supplementation of formula with LCPUFA is safe and of benefit to term infants.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, April, 2011), MEDLINE (1966 to April 2011), EMBASE (1980 to April 2011), CINAHL (December 1982 to April 2011) and abstracts of the Society for Pediatric Research (1980 to 2010). No language restrictions were applied.

SELECTION CRITERIA

Randomised and quasi randomised trials comparing LCPUFA supplemented vs. non-supplemented formula milk and with clinical endpoints were reviewed.

DATA COLLECTION AND ANALYSIS

Methodological quality of studies was assessed using the guidelines of Cochrane neonatal review group. Data were sought regarding effects on visual acuity, neurodevelopmental outcomes and physical growth. When appropriate, meta-analysis was conducted to provide a pooled estimate of effect.

MAIN RESULTS

Twenty-five randomised studies were identified; fifteen were included (n = 1889) and ten excluded.Visual acuity was assessed by nine studies. Visual evoked potential was used in six studies, two used Teller cards and one used both. Four studies reported beneficial effects while the remaining five did not.Neurodevelopmental outcome was measured by eleven studies. Bayley scales of infant development (BSID) was used in nine studies; only two showed beneficial effects. Meta-analysis did not show significant benefits of supplementation. One study followed the infants up to nine years of age and did not find benefit of supplementation. One study reported better novelty preference measured by Fagan Infant test at nine months. Another study reported better problem solving at 10 months. One study used Brunet and Lezine test to assess the developmental quotient and did not find beneficial effects.Physical growth was measured by thirteen studies; none found beneficial or harmful effects of supplementation. Meta-analysis found that supplemented group may have marginally lower weight at one year of age.

AUTHORS' CONCLUSIONS

Majority of the RCTS have not shown beneficial effects of LCPUFA supplementation on the neurodevelopmental outcomes of term infants. The beneficial effects on visual acuity have not been consistently demonstrated. Routine supplementation of term infant milk formula with LCPUFA can not be recommended.

Prenatal and early postnatal supplementation with long-chain polyunsaturated fatty acids: neurodevelopmental considerations

It takes >20 y before the human brain obtains its complex adult configuration. Most dramatic neurodevelopmental changes occur prenatally and early postnatally, including a major transformation in cortical organization 3-4 mo after term. The long-lasting changes have practical implications for studies evaluating the effect of prenatal and early postnatal supplementation with long-chain polyunsaturated fatty acids (LC-PUFAs). Whether studies of the effect of supplementation will reveal an effect not only depends on the dosage and duration of supplementation but also on 1) the timing of supplementation, 2) the age at which the outcome is assessed, 3) the application of age-specific sensitive neurodevelopmental tools, and 4) the functional domain evaluated. Studies of the effects of prenatal supplementation with docosahexaenoic acid (DHA) or fish oil have provided inconsistent results. However, maternal and neonatal concentrations of DHA and arachidonic acid are associated with improved outcomes in early infancy, and concentrations of DHA are associated with favorable neurodevelopmental outcome beyond early infancy. Studies of LC-PUFA supplementation in preterm infants have not shown evidence of a positive effect on neurodevelopmental outcome. Similar studies in full-term infants have indicated that supplementation with 0.30% DHA (by wt) promotes neurodevelopmental outcome in early infancy, but positive effects on later outcome have not been shown. However, information on the effects on outcomes at school age or later is virtually absent. This article stresses the need for long-term longitudinal studies that apply age-specific, sensitive neurodevelopmental tools, which also take into account lifestyle habits, maternal prepregnancy nutritional status, and genetic variation in metabolism.

Decreased postnatal docosahexaenoic and arachidonic acid blood levels in premature infants are associated with neonatal morbidities

OBJECTIVE

To measure the changes in whole blood fatty acid levels in premature infants and evaluate associations between these changes and neonatal morbidities.

STUDY DESIGN

This was a retrospective cohort study of 88 infants born at <30 weeks' gestation. Serial fatty acid profiles during the first postnatal month and infant outcomes, including chronic lung disease (CLD), retinopathy of prematurity, and late-onset sepsis, were analyzed. Regression modeling was applied to determine the association between fatty acid levels and neonatal morbidities.

RESULTS

Docosahexaenoic acid (DHA) and arachidonic acid levels declined rapidly in the first postnatal week, with a concomitant increase in linoleic acid levels. Decreased DHA level was associated with an increased risk of CLD (OR, 2.5; 95% CI, 1.3-5.0). Decreased arachidonic acid level was associated with an increased risk of late-onset sepsis (hazard ratio, 1.4; 95% CI, 1.1-1.7). The balance of fatty acids was also a predictor of CLD and late-onset sepsis. An increased linoleic acid:DHA ratio was associated with an increased risk of CLD (OR, 8.6; 95% CI, 1.4-53.1) and late-onset sepsis (hazard ratio, 4.6; 95% CI, 1.5-14.1).

CONCLUSION

Altered postnatal fatty acid levels in premature infants are associated with an increased risk of CLD and late-onset sepsis.

Long-chain polyunsaturated fatty acid supplementation in infancy reduces heart rate and positively affects distribution of attention

A double-blind, randomized, controlled, parallel-group prospective trial was conducted to determine whether a dose-response existed for four different levels of docosahexaenoic acid (DHA) supplementation on the cognitive performance of infants. A total of 122 term infants were fed one of four different formulas varying in their DHA composition (0.00, 0.32, 0.64, and 0.96% of total fatty acids as DHA) from birth to 12 mo. The three DHA-supplemented formulas also contained 0.64% of total fatty acids as arachidonic acid (ARA, 20:4n-6). Infants were tested at 4, 6, and 9 mo of age on a visual habituation protocol that yielded both behavioral and psychophysiological indices of attention. Infants in all DHA+ARA-supplemented conditions had lower heart rates than those in the unsupplemented condition; there was no dose-response for this effect. The distribution of time that infants spent in different phases of attention (a cognitive index derived from the convergence of behavioral and cardiac responses) varied as a function of dosage. Infants supplemented at the two lower DHA doses spent proportionately more time engaged in active stimulus processing than infants fed the unsupplemented formula, whereas infants fed the highest dose were intermediate and did not differ from any other group.

Prenatal DHA status and neurological outcome in children at age 5.5 years are positively associated

Beneficial effects of perinatal DHA supply on later neurological development have been reported. We assessed the effects of maternal DHA supplementation on the neurological development of their children. Healthy pregnant women from Spain, Germany, and Hungary were randomly assigned to a dietary supplement consisting of either fish oil (FO) (500 mg/d DHA + 150 mg/d EPA), 400 μg/d 5-methyltetrahydrofolate, both, or placebo from wk 20 of gestation until delivery. Fatty acids in plasma and erythrocyte phospholipids (PL) were determined in maternal blood at gestational wk 20 and 30 and in cord and maternal blood at delivery. Neurological development was assessed with the Hempel examination at the age of 4 y and the Touwen examination at 5.5 y. Minor neurological dysfunction, neurological optimality score (NOS), and fluency score did not differ between groups at either age, but the odds of children with the maximal NOS score increased with every unit increment in cord blood DHA level at delivery in plasma PL (95% CI: 1.094-2.262), erythrocyte phosphatidylethanolamine (95% CI: 1.091-2.417), and erythrocyte phosphatidylcholine (95% CI: 1.003-2.643). We conclude that higher DHA levels in cord blood may be related to a better neurological outcome at 5.5 y of age.

Achieving definitive results in long-chain polyunsaturated fatty acid supplementation trials of term infants: factors for consideration

Numerous randomized controlled trials (RCTs) have been undertaken to determine whether supplementation with long-chain polyunsaturated fatty acids (LCPUFAs) in infancy would improve the developmental outcomes of term infants. The results of such trials have been thoroughly reviewed with no definitive conclusion as to the efficacy of LCPUFA supplementation. A number of reasons for the lack of conclusive findings in this area have been proposed. This review examines such factors with the aim of determining whether an optimal method of investigation for RCTs of LCPUFA supplementation in term infants can be ascertained from previous research. While more research is required to completely inform a method that is likely to achieve definitive results, the findings of this literature review indicate future trials should investigate the effects of sex, genetic polymorphisms, the specific effects of LCPUFAs, and the optimal tests for neurodevelopmental assessment. The current literature indicates a docosahexaenoic acid dose of 0.32%, supplementation from birth to 12 months, and a total sample size of at least 286 (143 per group) should be included in the methodology of future trials.

Cognitive function in 18-month-old term infants of the DIAMOND study: a randomized, controlled clinical trial with multiple dietary levels of docosahexaenoic acid

BACKGROUND

Studies investigating cognitive outcomes following docosahexaenoic acid (DHA) supplementation of infant formula yield conflicting results, perhaps due to inadequate dietary concentrations.

AIM

To determine the optimal DHA concentration in term formula to support cognitive maturation.

DESIGN

This was a double-masked, randomized, controlled, prospective trial. A total of 181 infants were enrolled at 1-9 days of age and assigned randomly to receive one of four term infant formulas with one of four levels of docosahexaenoic acid: Control (0% DHA), 0.32% DHA, 0.64% DHA, or 0.96% DHA. All DHA-supplemented formulas contained 0.64% arachidonic acid (ARA). Infants were fed the assigned formulas until 12 months of age. One hundred forty-one children completed the 12-month feeding trial and were eligible for this study. Cognitive function was assessed in 131 children at 18 months of age using the Bayley Scales of Infant Development II (BSID II).

RESULTS

There were no diet group differences on the Mental Development Index (MDI), the Psychomotor Development Index (PDI), or the Behavior Rating Scale (BRS) of the BSID II. However, when the scores of children who received any of the three DHA-supplemented formulas were combined and compared to control children, a significant difference emerged: the MDI scores of DHA-supplemented children were higher (104.1 v. 98.4; p=0.02).

CONCLUSIONS

These results suggest that dietary supplementation of DHA during the first year of life leads to enhanced cognitive development at 18 months of age. DHA concentration of 0.32% is adequate to improve cognitive function; higher concentrations did not confer additional benefit.

Formula milk and neurodevelopmental and cognitive outcomes: where are we now?

The hypothesis that nutrition during critical windows in fetal and early life can program long-term health is intriguing and has a potentially strong implication for public health and pediatric nutritional practice. Specifically, it has been hypothesized that there are critical periods in the differentiation and maturation of the central nervous system during which environmental and nutritional factors can produce long-term structural and/or functional changes. Many studies have focused on the relationship between nutrition during early life and long-term neurodevelopmental outcome, leading to contrasting results: in fact, although experimental data in animals and short-term follow-up studies indicate a possible relationship between nutrition during early life and neurodevelopment, the results of long-term follow-up studies are more controversial and less convincing.

Early docosahexaenoic acid supplementation of mothers during lactation leads to high plasma concentrations in very preterm infants

Very preterm infants are vulnerable to deficiency in DHA. In a longitudinal study, 10 mothers who delivered ≤29 wk gestation and planned to breast-feed received DHA (1200 mg/d) until 36 wk after conception. The plasma DHA status was assessed in their 12 infants (including 2 pairs of twins) from birth to d 49. Fatty acid profiles were measured weekly in breast milk, and in plasma of mothers and infants at baseline and at d15 and 49. Plasma and breast milk fatty acid concentrations in the DHA-supplemented group at d 49 were compared with a reference group of very preterm infants (n = 24, including triplets) whose mothers (n = 22) did not receive DHA during lactation. The infants' plasma DHA concentration tended to be greater in the DHA group than in the reference group (P = 0.10) and was greater when expressed as a percentage of total fatty acids (P = 0.009). At d 49, maternal milk DHA in the DHA group (1.92 ± 1.10 mmol/L) was ~12 times higher than in the reference group (0.15 ± 0.27 mmol/L) (P < 0.001). The amount of DHA provided to the infants increased from wk 1 through wk 7 in the DHA group (P < 0.001). Although enteral intake at wk 7 did not differ between the DHA group [119 ± 51 mL/(kg·d)] and the reference group [113 ± 66 mL/(kg·d)], DHA group infants received 55 ± 38 mg/(kg·d) of DHA, and the reference group infants received 7 ± 11 mg/(kg·d) (P < 0.001). Early supplementation with DHA to lactating mothers with low dietary DHA intake successfully increased the plasma DHA status in very preterm infants.

Effects of iron supplementation in nonanemic pregnant women, infants, and young children on the mental performance and psychomotor development of children: a systematic review of randomized controlled trials

BACKGROUND

Uncertainty exists regarding the effects of iron supplementation on neurodevelopmental outcomes in the absence of anemia.

OBJECTIVE

Our objective was to evaluate the effects of iron supplementation in nonanemic pregnant women and in nonanemic healthy children aged <3 y on the mental performance and psychomotor development of children.

DESIGN

In this systematic review, MEDLINE, EMBASE, and The Cochrane Library were searched through December 2009 for randomized controlled trials (RCTs).

RESULTS

None of 5 RCTs individually showed a beneficial effect of iron supplementation during early life on the Mental Developmental Index of the Bayley Scales of Infant Development at different ages throughout the first 18 mo. Meta-analysis of 3 RCTs (n = 561) showed that, compared with placebo, supplementation with iron had no significant effect on children's Mental Developmental Index at approximately 12 mo of age (weighted mean difference: 1.66; 95% CI: -0.14, 3.47). Three of 5 RCTs showed a beneficial effect of iron supplementation on the Psychomotor Development Index at some time points, whereas 2 did not. Meta-analysis of 3 RCTs (n = 561) showed significant improvement on the Psychomotor Development Index at approximately 12 mo of age in the iron-supplemented group compared with the control group (weighted mean difference: 4.21; 95% CI: 2.31, 6.12). Two RCTs showed no effect of iron supplementation on behavior. Neither of the 2 RCTs that addressed the influence of prenatal iron supplementation showed an effect of iron on either the intelligence quotient or behavioral status of the children.

CONCLUSION

Limited available evidence suggests that iron supplementation in infants may positively influence children's psychomotor development, whereas it does not seem to alter their mental development or behavior.

Docosahexaenoic acid (DHA) and the developing central nervous system (CNS) - Implications for dietary recommendations

The accretion of docosahexaenoic acid (DHA) in membranes of the central nervous system is required for the optimum development of retina and brain functions. DHA status is determined by the dietary intake of n-3 polyunsaturated fatty acids (PUFA), both the metabolic precursor α-linolenic acid (α-LNA) and DHA. Clinical studies have shown that feeding term or premature infants with formula low in total n-3 PUFA may alter the maturation of visual acuity. Moreover, feeding infants over the first 6 mon of life with formula containing adequate α-LNA, but no DHA, did not sustain the same cerebral accretion of DHA as that of breast-fed infants. Whether lower DHA accretion in brain of formula-fed term infants impairs neurophysiological performances is not clearly established. Contradictory data have been published, possibly owing to confounding factors such as maternal intakes and/or genetic variations in PUFA metabolism. Nevertheless, a large corpus of data is in favor of the recommendation of regular dietary intakes of DHA (during at least the first 6 mon of life) and suggest that DHA should be added in formulas at the level generally found in human milk (0.2-0.3 wt% of total fatty acids). The maternal intake of n-3 PUFA during pregnancy and lactation is also crucial, since the n-3 PUFA are provided during perinatal development through placental transfer and maternal milk, which determines the DHA status of the newborn and consequently impacts on post-natal development of brain and visual functions. Whether more clinical studies are needed to control and improve the impact of DHA maternal intakes on the progeny's neurodevelopment, several commissions recommended by precaution that DHA average intake for pregnant and lactating women should be of 200-300 mg/day.

Lipid digestion and absorption in early life: an update

PURPOSE OF REVIEW

To highlight our understanding of digestion and absorption of dietary lipids in newborn infants, and specifically how these processes differ from those in children and adults.

RECENT FINDINGS

The intestinal concentration of pancreatic triglyceride lipase (PTL) and bile salts is lower in newborns compared to later in life. Instead the PTL-related protein 2 and bile salt-stimulated lipase (BSSL) are the key enzymes secreted from pancreas, which in concerted action with gastric lipase operate to achieve efficient fat absorption during infancy. BSSL is also present in human milk which affects fat absorption and growth in breast-fed preterm infants. Under conditions of low luminal bile salt concentrations fat absorption is likely to occur from liquid crystalline product phases, which may result in absorption from an extended part of the small intestinal mucosal surfaces compared to adults. Chylomicron assembly and secretion also seem to adapt to the specific situation of the newborn.

SUMMARY

Both fat digestion and product absorption are different in newborn infants compared to adults; other lipases are used for digestion and different physical-chemical phases may be used for product absorption. Why these differences occur is still an unsolved question of considerable importance to neonatal nutrition.