Lower protein in infant formula is associated with lower weight up to age 2 y: a randomized clinical trial

Animal and plant protein intake during infancy and childhood DNA methylation: a meta-analysis in the NutriPROGRAM consortium

BACKGROUND

Higher early-life animal protein intake is associated with a higher childhood obesity risk compared to plant protein intake. Differential DNA methylation may represent an underlying mechanism.

METHODS

We analysed associations of infant animal and plant protein intakes with DNA methylation in early (2-6 years, N = 579) and late (7̄-12 years, N = 604) childhood in two studies. Study-specific robust linear regression models adjusted for relevant confounders were run, and then meta-analysed using a fixed-effects model. We also performed sex-stratified meta-analyses. Follow-up analyses included pathway analysis and eQTM look-up.

RESULTS

Infant animal protein intake was not associated with DNA methylation in early childhood, but was associated with late-childhood DNA methylation at cg21300373 (P = 4.27 × 10¯8, MARCHF1) and cg10633363 (P = 1.09 × 10¯7, HOXB9) after FDR correction. Infant plant protein intake was associated with early-childhood DNA methylation at cg25973293 (P = 2.26 × 10-7, C1orf159) and cg15407373 (P = 2.13 × 10-7, MBP) after FDR correction. There was no overlap between the findings from the animal and plant protein analyses. We did not find enriched functional pathways at either time point using CpGs associated with animal and plant protein. These CpGs were not previously associated with childhood gene expression. Sex-stratified meta-analyses showed sex-specific DNA methylation associations for both animal and plant protein intake.

CONCLUSION

Infant animal protein intake was associated with DNA methylation at two CpGs in late childhood. Infant plant protein intake was associated with DNA methylation in early childhood at two CpGs. A potential mediating role of DNA methylation at these CpGs between infant protein intake and health outcomes requires further investigation.

World Health Organization (WHO) guideline on the complementary feeding of infants and young children aged 6-23 months 2023: A multisociety response

The recent World Health Organization (WHO) guideline aims to provide evidence-based recommendations on complementary feeding (CF) of healthy term infants and young children 6-23 months living in low-, middle-, and high-income countries, including both breastfed and non-breastfed children. Like WHO, our organizations aim to promote optimal infant and young child nutrition and health, with a focus on promoting breastfeeding as well as appropriate and timely CF. In this paper, we share our concerns about aspects of the guideline, some of which may have the potential to cause unintended harm in infants and young children and suggest alternative or modified proposals.

Association between protein-to-energy ratio and overweight/obesity in children and adolescents in the United States: a cross-sectional study based on NHANES

Background

The dietary protein proportion may be crucial in triggering overweight and obesity among children and adolescents.

Methods

Cross-sectional data from 4,336 children and adolescents who participated in the National Health and Nutrition Survey (NHANES) between 2011 and March 2020 were analyzed. Multivariate logistic regression was used to calculate odds ratio (OR) and 95% confidence interval (CI). Restricted cubic splines assessed the nonlinear relationships between dietary protein intake and the prevalence of overweight and obesity.

Results

Adjusted logistic regression models showed that each 1% increase in dietary protein proportion was associated with a 4% higher risk of overweight and obesity (OR = 1.04, 95% CI: 1.01-1.07). A nonlinear relationship was noted in children aged 6-11 years (P < 0.05), as demonstrated by restricted cubic spline analysis. After dividing dietary protein intake into quartiles, the highest quartile had an adjusted OR of 2.07 (95% CI: 1.35, 3.16, P = 0.001) compared to the lowest, among children aged 6-11 years.

Conclusion

Dietary protein intake is positively linked to overweight and obesity in American children, irrespective of individual characteristics and total energy consumption.

Infant feeding practices and body mass index up to 7.5 years in the French nationwide ELFE study

BACKGROUND/OBJECTIVES

The infant diet represents one of the main modifiable determinants of early growth. This study aimed to investigate the associations of infant feeding practices with body mass index (BMI) until 7.5 years.

SUBJECTS/METHODS

Analyses were based on data from the French nationwide ELFE birth cohort. Data on breastfeeding (BF) and complementary feeding (CF) were collected monthly from 2 to 10 months. Infant feeding practices were characterized using principal component analyses (PCA) and hierarchical ascendant classification. BMI z-score was computed at 1, 2, 3, 5 and 7.5 years, from data collected in the child's health booklet; 7.5-year overweight was defined according to IOTF references. Associations between infant feeding practices and BMI were investigated by linear regression models adjusted for main confounders.

RESULTS

Ever breastfeeding was not associated with BMI up to 7.5 years. Compared to intermediate breastfeeding duration (1 to <3 months), longer breastfeeding duration (≥6 months) was related to lower 1-year BMI, but not at older ages. Compared to the recommended age at CF introduction (4-6 months), early CF (<4 months) was related to higher BMI up to 5 years with a similar trend at 7.5 years, but not to the risk of overweight. The PCA patterns characterized by early baby cereal introduction and late food pieces introduction or by frequent intake of main food groups were related to a lower BMI up to 7.5 years.

CONCLUSION

Breastfeeding was related with a lower BMI in infancy but not thereafter, whereas an early CF initiation (<4 months) was associated with a higher BMI in childhood.

Low-Protein Infant Formula Enriched with Alpha-Lactalbumin during Early Infancy May Reduce Insulin Resistance at 12 Months: A Follow-Up of a Randomized Controlled Trial

High protein intake during infancy results in accelerated early weight gain and potentially later obesity. The aim of this follow-up study at 12 months was to evaluate if modified low-protein formulas fed during early infancy have long-term effects on growth and metabolism. In a double-blinded RCT, the ALFoNS study, 245 healthy-term infants received low-protein formulas with either alpha-lactalbumin-enriched whey (α-lac-EW; 1.75 g protein/100 kcal), casein glycomacropeptide-reduced whey (CGMP-RW; 1.76 g protein/100 kcal), or standard infant formula (SF; 2.2 g protein/100 kcal) between 2 and 6 months of age. Breastfed (BF) infants served as a reference. At 12 months, anthropometrics and dietary intake were assessed, and serum was analyzed for insulin, C-peptide, and insulin-like growth factor 1 (IGF-1). Weight gain between 6 and 12 months and BMI at 12 months were higher in the SF than in the BF infants (p = 0.019; p < 0.001, respectively), but were not significantly different between the low-protein formula groups and the BF group. S-insulin and C-peptide were higher in the SF than in the BF group (p < 0.001; p = 0.003, respectively), but more alike in the low-protein formula groups and the BF group. Serum IGF-1 at 12 months was similar in all study groups. Conclusion: Feeding modified low-protein formula during early infancy seems to reduce insulin resistance, resulting in more similar growth, serum insulin, and C-peptide concentrations to BF infants at 6-months post intervention. Feeding modified low-protein formula during early infancy results in more similar growth, serum insulin, and C-peptide concentrations to BF infants 6-months post intervention, probably due to reduced insulin resistance in the low-protein groups.

Safety and Suitability of Infant Formula Manufactured from Extensively Hydrolyzed Whey Protein Compared to Intact Protein: A Combined Analysis of Two Randomized Controlled Studies

Our aim was to assess the nutritional safety and suitability of an infant formula manufactured from extensively hydrolyzed protein in comparison to infant formula manufactured from intact protein (both with low and standard protein content). We performed a combined analysis of raw data from two randomized infant feeding studies. An analysis of covariance (ANCOVA) model was used to determine the non-inferiority of daily weight gain (primary outcome; margin -3 g/day), with the intervention group as a fixed factor and geographic region, sex, and baseline weight as covariates (main model). The data of 346 infants exposed to the formula were included in the analysis. The sample size of the per-protocol analysis with 184 infants was too small to achieve sufficient statistical power. The lower limit of the 97.5% confidence interval (-0.807) of the mean group difference in daily weight gain (i.e., 2.22 g/day) was above the -3 g/day margin (full analysis set). Further anthropometric parameters did not differ between the infant formula groups throughout the study. Growth was comparable to breastfed infants. We conclude that the infant formula manufactured from extensively hydrolyzed protein meets infant requirements for adequate growth and does not raise any safety concerns.

Protein Restriction in Metabolic Health: Lessons from Rodent Models

Consumption of protein-rich diets and supplements has been increasingly advocated by individuals seeking to optimize metabolic health and mitigate the effects of aging. Protein intake is postulated to support muscle mass retention and enhance longevity, underscoring its perceived benefits in age-related metabolic regulation. However, emerging evidence presents a paradox; while moderate protein consumption contributes to health maintenance, an excessive intake is associated with an elevated risk of chronic diseases, notably obesity and diabetes. Furthermore, recent studies suggest that reducing the ratio of protein intake to macronutrients improves metabolic parameters and extends lifespan. The aim of this study is to review the current evidence concerning the metabolic effects of protein-restricted diets and their potential mechanisms. Utilizing rodent models, investigations have revealed that protein-restricted diets exert a notable influence over food intake and energy consumption, ultimately leading to body weight loss, depending on the degree of dietary protein restriction. These phenotypic alterations are primarily mediated by the FGF21 signaling pathway, whose activation is likely regulated by ATF4 and the circadian clock. The evidence suggests that protein-restricted diets as an alternative approach to calorie-restricted regimes, particularly in overweight or obese adults. However, more research is needed to determine the optimal level of restriction, duration, and long-term effects of such interventions.

Infant Milk Formula with Large, Milk Phospholipid-coated Lipid Droplets Enriched in Dairy Lipids Affects Body Mass Index Trajectories and Blood Pressure at School Age: Follow-up of a Randomized Controlled Trial

BACKGROUND

Human milk comprises large fat globules enveloped by a native phospholipid membrane, whereas infant formulas contain small, protein-coated lipid droplets. Previous experimental studies indicated that mimicking the architecture of human milk lipid droplets in infant milk formula (IMF) alters lipid metabolism with lasting beneficial impact on later metabolic health.

OBJECTIVES

To evaluate in a follow-up (FU) study of a randomized, controlled trial whether a Concept IMF with large, milk phospholipid-coated lipid droplets enriched with dairy lipids beneficially impacts long-term body mass index (BMI in kg/m2) trajectories and blood pressure at school age.

METHODS

Fully formula-fed infants were randomly assigned to Concept IMF (n = 115) or Control IMF with conventional, small lipid droplets containing vegetable oils (n = 108) for the first 4 mo of age. A group of 88 breastfed infants served as a reference. During FU, anthropometrics were collected at 1, 3, 4, and 5 y of age, and blood pressure only at the last visit.

RESULTS

Compared to Control, Concept group children had consistently lower mean BMI values during FU, with the most marked difference at 1 y of age (difference in means -0.71 kg/m2, 95% confidence interval (CI): -1.13, -0.29; P = 0.001); mean values were close to the breastfed group (P > 0.05). Contrary, the mean BMI values of the Control group were higher compared with the breastfed group during FU from 1 to 5 y of age (differences in means from 0.59 to 0.96 kg/m2, respectively; P < 0.02). At 5 y of age, the Concept group had a lower mean diastolic and arterial blood pressure compared with the Control group; -4.3mm Hg (95% CI: -7.3, -1.3; P = 0.005) and -3.7 mm Hg (95% CI: -6.5, -0.9; P = 0.01), respectively.

CONCLUSIONS

Early life feeding of an innovative IMF with large, milk phospholipid-coated lipid droplets enriched with dairy lipids results in a BMI trajectory closer to breastfed infants and a lower blood pressure at school age. This trial was registered at the Dutch Trial Register as NTR3683 and NTR5538.

A repeated cross-sectional analysis of the Icelandic baby food market surveyed in 2016, 2019 and 2021

World Health Organisation (WHO) has stated that countries need to know their local commercial baby food (CBF) market. Data from other countries suggest rapid changes in CBF options, highlighting the need for repeated analysis. In that context, this repeated cross-sectional study analysed the options and nutrient quality of different CBF types available in Iceland in years 2016, 2019 and 2021. Data was gathered on formulas, porridge flours, foods in jars and pouches, finger-foods, other CBF. They were classified into 26 subgroups based on ingredients and taste (sweet/savoury). Minimum consumer age as suggested by the manufacturers and nutritional content were registered. In each data-collection, 250-275 products were available. Over a third of products (37%-44%) were in pouches. Availability of products intended for 4-11-month-old infants decreased, driven largely by a 65% decrease in availability of food in jars (sweet/savoury) between 2016 and 2021. Availability of products intended from 12+ months or without age-labels increased, driven largely by quadrupling of finger-foods (predominantly sweet) between 2016 and 2021. The overall percentage of products classified as sweet increased from 65% (2016) to 73% (2019) and 77% (2021). Some finger-foods had high sugar content (up to 72 g/100 g), partly from fruit concentrate or sugar/syrup. Like other countries, the Icelandic CBF market has moved towards less availability of food intended in the first year and more availability of sweet finger-foods for an expanded consumer age. As sugar is added to some CBF, stronger regulations on promotion of foods for young consumers and updated recommendations for parents/caregivers may be needed.

Breastfeeding and the Longitudinal Changes of Body Mass Index in Childhood and Adulthood: A Systematic Review

Mounting evidence supports the beneficial role of breastfeeding in lowering obesity risk, but the enduring impact of breastfeeding on longitudinal changes in body mass index (BMI) (i.e., BMI trajectories) remains unclear. This systematic review summarized evidence on how breastfeeding influenced the longitudinal trajectories of BMI later in life. Literature searches were conducted in Medline, Embase, Web of Science, and ScienceDirect to identify studies that assessed how breastfeeding (versus other feeding types or duration) was associated with longitudinal trajectories of BMI or BMI z-score. Three randomized controlled trials (RCTs) and 24 longitudinal cohort studies were included. Two-thirds (18/27) of studies were rated as acceptable or high quality. Most cohort studies (9/11) showed that children who continued to breastfeed at 3 to 12 mo of age had a lower BMI trajectory or lower odds of following a high BMI trajectory than those who were formula-fed or mixed-fed. The BMI differences between breastfeeding and other feeding groups were evident from age 7 mo and remained up to 8 y, and the magnitude of between-group BMI differences increased with age. For breastfeeding duration, 12 out of 15 cohort studies found that longer breastfeeding duration was associated with lower BMI trajectories up to age 18 y. Moreover, beneficial associations were observed for both exclusive and any breastfeeding with BMI trajectory. In contrast, mixed findings were reported from 3 RCTs that compared BMI trajectories from birth to ages 12 to 24 mo between breastfeeding promotion versus control or breastfeeding versus formula-feeding groups. The current review provides further longitudinal evidence from cohort studies that breastfeeding versus formula/mixed feeding or longer breastfeeding duration was associated with lower BMI trajectories. Such associations initiated in early childhood became more apparent with age and were sustained into early adulthood. The existing evidence substantiates the importance of breastfeeding promotion and continuation to support obesity prevention.

Protein - a scoping review for Nordic Nutrition Recommendations 2023

Proteins are needed for providing essential amino acids, nitrogen, and fuel for the body's needs in all age groups. Proteins are especially required during active growth in pregnancy, lactation, childhood, and tissue growth in general. An adequate protein intake is needed in old adults to avoid premature muscle loss. According to the current dietary surveys, protein intake in the Nordic and Baltic countries varies from 15 to 19% of the total energy intake in adults. Comprehensive data regarding children and older adults are lacking. No good measure for protein status exists, and the estimation of physiological requirements is based on N-balance studies having some weaknesses. Protein quality is assessed by considering the protein digestibility of individual indispensable amino acids and their utilization (bioavailability), which is affected by food antinutrients and processing. The evidence regarding the association of protein intake per se with health outcomes is limited or suggestive. It is difficult to separate from the effect of other nutrients or ingredients in protein-rich foods. Proteins are widespread in foods, deriving from both animal and plant sources. Animal-sourced protein production puts more strain on the environment than plant-sourced proteins and contributes significantly to greenhouse gas emissions, thereby enhancing climate change. In Nordic and Baltic countries, consumption of animal-sourced proteins is relatively high. A shift toward more plant-based protein diets would be advisable for promoting a healthy and sustainable diet.

Causes of possible excessive weight gain in exclusively breastfed infants in the first six months of life

BACKGROUND

The aim of this study was to describe factors related to the infant, mother, and breastmilk composition that may be associated with excessive weight gain in a cohort of exclusively breastfed infants younger than 6 months of life with excessive weight gain, and to compare these findings with data from a group of normal-weight exclusively breastfed infants.

METHODS

Thirty-six exclusively breastfed infants younger than 6 months of life seen at two health-care centers between July 2016 and 2017 were enrolled in the study. The clinical features of the infants, their mothers, and the macronutrient composition of the breast milk were evaluated. We classified infants according to weight gain velocity between birth and 6 months of life into an excessive weight gain (EWG) and an adequate weight gain (AWG) group.

RESULTS

Mean age at protocol entry was 3.8 months. Thirteen patients were classified as EWG and 23 patients as AWG. Co-sleeping was more often observed in EWG than in AWG infants. Mothers in the EWG group were younger and more often had gained more than 18 kg during pregnancy than those in the AWG group. No significant differences were found in the macronutrient content of the breast milk between both groups.

CONCLUSIONS

Greater weight gain in infants under 6 months of age may be related to greater weight gain of the mother during pregnancy, younger age of the mother, and co-sleeping of the mother and child.

[Frequency of Utilization of Medical and Paramedical Care in Infants with Excessive Crying: Cross- Sectional Analysis and Parent Survey]

BACKGROUND

Infants can present in the first year of life with excessive, recurrent crying without an apparent illness or failure to thrive. The excessive crying results in a wide variety of problems for infants, parents and health care service.

OBJECTIVES

This study aimed at evaluating how often parents of children with excessive crying seek help in the medical and paramedical health care system and which therapies are prescribed.

MATERIALS AND METHODS

This study uses data collected within KUNO Kids health study. Families who participated completed questionnaires 4 weeks after birth and answered questions which screened for excessive crying. Families whose child was screened positive completed an additional questionnaire on symptoms, parental management and health care utilization. Data were analysed using descriptive statistics.

RESULTS

We received 238 questionnaires from children with excessive crying, 105 fulfilled the modified Wessel criteria. Of these 37 children (36%) were seen by a pediatrician because of crying. 57 (55%) received medications by the pediatrician. 51 (49%) of the parents specified that they also used paramedical therapies due to crying or whining, most often osteopathy. 45 (43%) adapted their own nutrition or their child's nutrition.

CONCLUSIONS

Our study shows that parents experience problems in dealing excessive crying. Frequent consultations with pediatricians or use of paramedical therapies are common, demanding additional resources. The parents received different diagnoses for excessive crying. Available drugs like Simeticon, homeopathy or manual therapy are recommended and applied despite largely missing evidence.

Higher versus lower protein intake in formula-fed term infants

BACKGROUND

Many infants are fed infant formulas to promote growth. Some formulas have a high protein content (≥ 2.5 g per 100 kcal) to accelerate weight gain during the first year of life. The risk-benefit balance of these formulas is unclear.

OBJECTIVES

To evaluate the benefits and harms of higher protein intake versus lower protein intake in healthy, formula-fed term infants.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, OpenGrey, clinical trial registries, and conference proceedings in October 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of healthy formula-fed infants (those fed only formula and those given formula as a complementary food). We included infants of any sex or ethnicity who were fed infant formula for at least three consecutive months at any time from birth. We excluded quasi-randomized trials, observational studies, and infants with congenital malformations or serious underlying diseases. We defined high protein content as 2.5 g or more per 100 kcal, and low protein content as less than 1.8 g per 100 kcal (for exclusive formula feeding) or less than 1.7 g per 100 kcal (for complementary formula feeding).

DATA COLLECTION AND ANALYSIS

Four review authors independently assessed the risk of bias and extracted data from trials, and a fifth review author resolved discrepancies. We performed random-effects meta-analyses, calculating risk ratios (RRs) or Peto odds ratios (Peto ORs) with 95% confidence intervals (CIs) for dichotomous outcomes, and mean differences (MDs) with 95% CIs for continuous outcomes. We used the GRADE approach to evaluate the certainty of the evidence.

MAIN RESULTS

We included 11 RCTs (1185 infants) conducted in high-income countries. Seven trials (1629 infants) compared high-protein formula against standard-protein formula, and four trials (256 infants) compared standard-protein formula against low-protein formula. The longest follow-up was 11 years. High-protein formula versus standard-protein formula We found very low-certainty evidence that feeding healthy term infants high-protein formula compared to standard-protein formula has little or no effect on underweight (MD in weight-for-age z-score 0.05 SDs, 95% CI -0.09 to 0.19; P = 0.51, I2 = 61%; 7 studies, 1629 participants), stunting (MD in height-for-age z-score 0.15 SDs, 95% CI -0.05 to 0.35; P = 0.14, I2 = 73%; 7 studies, 1629 participants), and wasting (MD in weight-for-height z-score -0.12 SDs, 95% CI -0.31 to 0.07; P = 0.20, I2 = 94%; 7 studies, 1629 participants) in the first year of life. We found very low-certainty evidence that feeding healthy infants high-protein formula compared to standard-protein formula has little or no effect on the occurrence of overweight (RR 1.26, 95% CI 0.63 to 2.51; P = 0.51; 1 study, 1090 participants) or obesity (RR 1.96, 95% CI 0.59 to 6.48; P = 0.27; 1 study, 1090 participants) at five years of follow-up. No studies reported all-cause mortality. Feeding healthy infants high-protein formula compared to standard-protein formula may have little or no effect on the occurrence of adverse events such as diarrhea, vomiting, or milk hypersensitivity (RR 0.93, 95% CI 0.76 to 1.13; P = 0.44, I2 = 0%; 4 studies, 445 participants; low-certainty evidence) in the first year of life. Standard-protein formula versus low-protein formula We found very low-certainty evidence that feeding healthy infants standard-protein formula compared to low-protein formula has little or no effect on underweight (MD in weight-for-age z-score 0.0, 95% CI -0.43 to 0.43; P = 0.99, I2 = 81%; 4 studies, 256 participants), stunting (MD in height-for-age z-score -0.01, 95% CI -0.36 to 0.35; P = 0.96, I2 = 73%; 4 studies, 256 participants), and wasting (MD in weight-for-height z-score 0.13, 95% CI -0.29 to 0.56; P = 0.54, I2 = 95%; 4 studies, 256 participants) in the first year of life. No studies reported overweight, obesity, or all-cause mortality. Feeding healthy infants standard-protein formula compared to low-protein formula may have little or no effect on the occurrence of adverse events such as diarrhea, vomiting, or milk hypersensitivity (Peto OR 1.55, 95% CI 0.70 to 3.40; P = 0.28, I2 = 0%; 2 studies, 206 participants; low-certainty evidence) in the first four months of life.

AUTHORS' CONCLUSIONS

We are unsure if feeding healthy infants high-protein formula compared to standard-protein formula has an effect on undernutrition, overweight, or obesity. There may be little or no difference in the risk of adverse effects between infants fed with high-protein formula versus those fed with standard-protein formula. We are unsure if feeding healthy infants standard-protein formula compared to low-protein formula has any effect on undernutrition. There may be little or no difference in the risk of adverse effects between infants fed with standard-protein formula versus those fed with low-protein formula. The findings of six ongoing studies and two studies awaiting classification studies may change the conclusions of this review.

Knowledge and Use of Paced Bottle-Feeding Among Mothers of Young Infants

OBJECTIVE

To describe mothers' awareness and use of paced bottle-feeding (PBF) and to investigate whether the use of PBF was associated with maternal characteristics and infant feeding practices.

METHODS

Cross-sectional, online survey. Participants were mothers of infants < 12 months of age (n = 197). Participants self-reported their awareness and use of PBF, demographic characteristics, and infant feeding practices.

RESULTS

Of the 41% of participants who indicated they had or maybe had heard of PBF, 23% used PBF and 35% sometimes used PBF. Use of PBF was not associated with mother or infant characteristics. Participants who used PBF were significantly less likely to encourage their infant to finish the bottle (odds ratio, 0.04; 95% confidence interval, 0.01-0.79).

CONCLUSIONS AND IMPLICATIONS

Paced bottle-feeding was associated with lower likelihood of one dimension of pressuring feeding practices, encouraging infant bottle-emptying. More research is needed to determine the effectiveness of PBF in promoting healthy feeding outcomes.

Infant body composition: A comprehensive overview of assessment techniques, nutrition factors, and health outcomes

Body composition assessment is a valuable tool for clinical assessment and research that has implications for long-term health. Unlike traditional measurements such as anthropometrics or body mass index, body composition assessments provide more accurate measures of body fatness and lean mass. Moreover, depending on the technique, they can offer insight into regional body composition, bone mineral density, and brown adipose tissue. Various methods of body composition assessment exist, including air displacement plethysmography, dual-energy x-ray absorptiometry, bioelectrical impedance, magnetic resonance imaging, D3 creatine, ultrasound, and skinfold thickness, each with its own strengths and limitations. In infants, several feeding practices and nutrition factors are associated with body composition outcomes, such as breast milk vs formula feeding, protein intake, breast milk composition, and postdischarge formulas for preterm infants. Longitudinal studies suggest that body composition in infancy predicts later body composition, obesity, and other cardiometabolic outcomes in childhood, making it a useful early marker of cardiometabolic health in both term and preterm infants. Emerging evidence also suggests that body composition during infancy predicts neurodevelopmental outcomes, particularly in preterm infants at high risk of neurodevelopmental impairment. The purpose of this narrative review is to provide clinicians and researchers with a comprehensive overview of body composition assessment techniques, summarize the links between specific nutrition practices and body composition in infancy, and describe the neurodevelopmental and cardiometabolic outcomes associated with body composition patterns in term and preterm infants.

Protein and growth during the first year of life: a systematic review and meta-analysis

Dietary protein intake in the first year of life might influence later growth. We conducted a systematic review to investigate the growth effects of interventions based on infant formula composition providing different amounts of protein within the first year of life of healthy term infants; in the absence of other comparable information over the investigated period, a meta-analysis further compared weight or length gain at 120 days from high- (>2.0 g/100 kcal) and low-protein (≤2.0 g/100 kcal) content formula groups. Twelve papers (n = 2275) were included and five of them (n = 677) contributed to the meta-analysis. Most studies compared a high-protein formula, a low-protein formula, and breastfeeding. Evidence from the systematic review was inconclusive due to heterogeneity in design and treatments. In the presence of modest heterogeneity but in the absence of publication bias, the weighted mean difference for weight gain at 120 days was -0.02 g/day (95% CI: -1.41, 1.45); with higher heterogeneity, the weighted MD estimate of length gain at 120 days was 0.004 cm/month (95% CI: -0.26, 0.27). Although limited and underpowered, evidence from the meta-analysis does not support the assumption that high- vs. low-protein content formulas during exclusive milk-feeding lead to different growth outcomes in the first months of life. Prospero registration number: CRD42017058535. IMPACT: The optimal amount of dietary protein that should be given to healthy full-term infants early in life is still debated. Despite heterogeneity in study design, treatments, and outcomes, this systematic review showed that there is no clear-cut effect on the growth of different amounts of protein intake from formulas or complementary feeding. Evidence from the meta-analysis based on the five articles enrolling infants <1 month of life does not support the previous assumption that high- vs. low-protein content formulas during exclusive milk-feeding lead to different growth outcomes in the first 4 months of life.

Does human milk composition predict later risk of obesity? A systematic review

BACKGROUND

Possible mechanisms behind the association of breastfeeding with a lower risk of later obesity are unknown but one possibility is the unique composition of human milk. Here, we systematically reviewed the evidence linking breast-milk macronutrient and hormonal composition with later obesity.

METHODS

We searched 7 databases for studies that included infants predominantly breast-fed for the first 3 months and which analysed associations between a measure of breast-milk composition and later (> 6 months) measures of obesity or body composition.

RESULTS

47 publications were identified for full-text screening, of which 10 were eligible and only 3 found significant associations. Higher leptin concentration in breast milk at age 1 month was associated with lower infant BMI at 12, 18 and 24 months of age (1 study). Higher breast-milk adiponectin concentration at 6 weeks and 4 months were associated with adiposity at age 12 and 24 months (1 study). In 1 study, breast-milk carbohydrate content was positively associated, and fat content negatively associated, with adiposity at age 12 months. No significant associations were found between other hormones or macronutrients in human milk and later risk of obesity or body composition.

CONCLUSIONS

The evidence linking breast-milk composition with later obesity was inconsistent and confined to single, individual studies. Our review highlights the methodological limitations of previous studies and the need for further research in this area.

Perspective: Assuring the Quality of Protein in Infant Formula

Current regulations require that the assessment of protein quality in infant formula be determined using the protein efficiency ratio (PER) rat bioassay where the growth of rats fed a test protein is compared with the growth of rats fed casein. This review cites authoritative body opinions that the PER is not a preferred method for scoring protein quality, particularly as applied to the infant formula. Methodological recommendations specified by FDA and recent guidance propose to control nonprotein dietary variables in the PER. In contrast, the essential amino acid pattern of human milk has been adopted internationally as the standard for protein quality in infant formula. Because casein, the control protein in the PER fails to meet the standard of human milk essential amino acids, the PER based on casein can generate a false assurance of the quality of protein in an infant formula. FDA should revise the method of demonstrating the quality factor for the biological quality of protein to the essential amino acid pattern of human milk, which would be simpler, conform to international standards, and should be considered by FDA under a new statute. Alternate methods of determination of protein quality can be used selectively when there are questions about the digestibility of new protein sources or the effects of manufacturing processes.

Obesity in Early Life: Its Causes, Prevention and Risks in Later Life

Being overweight or obese at the end of the first year of life is associated with an increased risk of obesity in later life and an increased risk of developing other diseases, like type 1 diabetes mellitus, cardiovascular disorders and psycho-social problems [...].

Low-Protein Diets Composed of Protein Recovered from Food Processing Supported Growth, but Induced Mild Hepatic Steatosis Compared with a No-Protein Diet in Young Female Rats

BACKGROUND

Living in low-income countries often restricts the consumption of adequate protein and animal protein.

OBJECTIVES

This study aimed to investigate the effects of feeding low-protein diets on growth and liver health using proteins recovered from animal processing.

METHODS

Female Sprague-Dawley rats (aged 28 d) were randomly assigned (n = 8 rats/group) to be fed standard purified diets with 0% or 10% kcal protein that was comprised of either carp, whey, or casein.

RESULTS

Rats that were fed low-protein diets showed higher growth but developed mild hepatic steatosis compared to rats that were fed a no-protein diet, regardless of the protein source. Real-time quantitative polymerase chain reactions targeting the expression of genes involved in liver lipid homeostasis were not significantly different among groups. Global RNA-sequencing technology identified 9 differentially expressed genes linked to folate-mediated 1-carbon metabolism, endoplasmic reticulum (ER) stress, and metabolic diseases. Canonical pathway analysis revealed that mechanisms differed depending on the protein source. ER stress and dysregulated energy metabolism were implicated in hepatic steatosis in carp- and whey-fed rats. In contrast, impaired liver one-carbon methylations, lipoprotein assembly, and lipid export were implicated in casein-fed rats.

CONCLUSIONS

Carp sarcoplasmic protein showed comparable results to commercially available casein and whey protein. A better understanding of the molecular mechanisms in hepatic steatosis development can assist formulation of proteins recovered from food processing into a sustainable source of high-quality protein.

Relationships between the Intakes of Human Milk Components and Body Composition of Breastfed Infants: A Systematic Review

Human milk provides all of the elements necessary for infant growth and development. Previous studies have reported associations between breastfeeding and a reduced risk of developing obesity and late-onset metabolic disorders; however, the underlying mechanisms are poorly understood. Recently, intakes of human milk components have been associated with infant body composition, which is likely partially implicated in the reduced risk of developing childhood obesity among breastfed infants. In this systematic review, we searched electronic bibliographic databases for studies that explored relationships between the 24 h intakes of human milk macronutrients and bioactive components and infant body composition and/or growth parameters. Of 13 eligible studies, 10 assessed relationships of infant body composition and growth outcomes with human milk macronutrients, while 8 studies assessed relationships with human milk bioactive components. Significant time-dependent relationships with infant anthropometrics and body composition were found for intakes and no relationships for concentrations of several human milk components, such as lactose, total protein, and human milk oligosaccharides, suggesting that measuring concentrations of human milk components without quantifying the intake by the infant may provide a limited understanding. Future studies investigating the effect of human milk components on infant growth and body composition outcomes should consider measuring the actual intake of components and employ standardised methods for measuring milk intake.

Equally Good Neurological, Growth, and Health Outcomes up to 6 Years of Age in Moderately Preterm Infants Who Received Exclusive vs. Fortified Breast Milk-A Longitudinal Cohort Study

Moderately preterm infants (32-36 weeks of gestational age) have an increased risk of worse health and developmental outcomes compared to infants born at term. Optimal nutrition may alter this risk. The aim of this study was to investigate the neurological, growth, and health outcomes up to six years of age in children born moderately preterm who receive either exclusive or fortified breast milk and/or formula in the neonatal unit. In this longitudinal cohort study, data were collected for 142 children. Data were collected up to six years of age via several questionnaires containing questions about demographics, growth, child health status, health care visits, and the Five to Fifteen Questionnaire. Data on the intake of breast milk, human milk fortification, formula, and growth during hospitalization were collected from the children's medical records. No statistically significant differences in neurological outcomes, growth, or health at six years of age were found between the two groups (exclusive breast milk, n = 43 vs. fortified breast milk and/or formula, n = 99). There is a need for research in larger populations to further assess potential effects on health and developmental outcomes when comparing the use of exclusive versus fortified breast milk for moderately preterm infants during neonatal hospitalization.

Membrane filtration processing of infant milk formula alters protein digestion in young pigs

Reducing heat treatment (HT) during processing of infant milk formula (IMF) is desirable to produce a product that more closely resembles breast milk. By employing membrane filtration (MEM), we produced an IMF (60:40 whey to casein ratio) at pilot scale (250 kg). MEM-IMF had a significantly higher content of native whey (59.9 %) compared to HT-IMF (4.5 %) (p < 0.001). Pigs, at 28 days old, were blocked by sex, weight and litter origin and assigned to one of two treatments (n = 14/treatment): (1) starter diet containing 35 % of HT-IMF powder or (2) starter diet containing 35 % of MEM-IMF powder for 28 days. Body weight and feed intake were recorded weekly. Pigs at day 28 post weaning were sacrificed 180 min after their final feeding, for the collection of gastric, duodenal, jejunum and ileal contents (n = 10/treatment). MEM-IMF diet resulted in more water-soluble proteins and higher levels of protein hydrolysis in the digesta at various gut locations compared to HT-IMF (p < 0.05). In the jejunal digesta, a higher concentration of free amino acids were present post MEM-IMF consumption (247 ± 15 µmol g^-1 of protein in digesta) compared to HT-IMF (205 ± 21 µmol g^-1 of protein). Overall, average daily weight gain, average dairy feed intake and feed conversion efficiency were similar for pigs fed either MEM-IMF or HT-IMF diets, but differences and trends to difference of these indicators were determined in particular intervention periods. In conclusion, reducing heat treatment during processing of IMF influenced protein digestion and revealed minor effects on growth parameters providing in vivo evidence that babies who are fed with IMF processed by MEM are likely to have different protein digestion kinetics but minimal effect on overall growth trajectories as babies fed IMF processed by traditional thermal processing.

Is It Time to Revise the Current Nutrient Requirements for Infant Formulas Principally Established in 1980?

Because of the production of nutrient-deficient infant formulas (IFs), the United States Congress passed regulations on the composition and production of IF, referred to as the Infant Formula Act (IFA), in 1980, which was amended in 1986. More detailed FDA rules have been created since then, specifying the ranges or minimum intakes of nutrients and providing details for the safe production and evaluation of infant formulas. Although generally effective in ensuring safe IF, recent events have made it clear that a re-evaluation of aspects of all the nutrient composition regulations for IF is needed, including consideration of adding requirements related to bioactive nutrients not mentioned in the IFA. We propose that, as principal examples, the requirement for iron content needs to be re-evaluated and that DHA and AA should be considered for addition to the nutrient requirements after scientific review by a panel such as those established by the National Academies of Sciences, Engineering, and Medicine. Additionally, there is no specific requirement in current FDA regulations for the energy density of IF, and this should be added alongside potential revisions of the protein requirement. It would also be ideal to have specific FDA rules on nutrient intakes for premature infants as these are exempted from the specific nutrient regulations of the amended IFA.

A randomized, controlled trial of a Nordic, protein-reduced complementary diet in infants: effects on body composition, growth, biomarkers and dietary intake at 12 and 18 months

BACKGROUND

High intake of protein and low intake of plant-based foods during complementary feeding (CF) can contribute to negative long-term health effects.

OBJECTIVES

To investigate the effects of a protein-reduced, Nordic complementary diet on body composition, growth, biomarkers and dietary intake, compared to current Swedish dietary recommendations for infants at 12 and 18 months.

DESIGN

Healthy, term infants (n=250) were randomly allocated to either a Nordic group (NG) or a conventional group (CG). From 4-6 months, NG participants received repeated exposures of Nordic taste portions. From 6 months to 18 months, NG was supplied with Nordic homemade baby food recipes, protein-reduced baby food products and parental support. CG followed the current Swedish dietary recommendations. Measurements of body composition, anthropometry, biomarkers and dietary intake were collected from baseline and at 12 and 18 months.

RESULTS

Of the 250 infants, 82% (n=206) completed the study. There were no group differences in body composition or growth. In NG, protein intake, blood urea nitrogen (BUN) and plasma insulin-like growth factor 1 (IGF-1) were lower compared to CG at 12 and 18 months. Infants in NG consumed 42-45% more fruits and vegetables compared to CG at 12 and 18 months, which was reflected in a higher plasma folate at 12 and 18 months. There were no between-group differences in energy intake (EI) or iron status.

CONCLUSIONS

Introduction of a predominantly plant-based, protein-reduced diet as part of complementary feeding is feasible and can increase fruit and vegetable intake.

CLINICAL TRIAL REGISTRY

OTIS; ClinicalTrials.gov registration number NCT02634749.

Low-Protein Formulas with Alpha-Lactalbumin-Enriched or Glycomacropeptide-Reduced Whey: Effects on Growth, Nutrient Intake and Protein Metabolism during Early Infancy: A Randomized, Double-Blinded Controlled Trial

Protein intake is higher in formula-fed than in breast-fed infants during infancy, which may lead to an increased risk of being overweight. Applying alpha-lactalbumin (α-lac)-enriched whey or casein glycomacropeptide (CGMP)-reduced whey to infant formula may enable further reduction of formula protein by improving the amino acid profile. Growth, nutrient intake, and protein metabolites were evaluated in a randomized, prospective, double-blinded intervention trial where term infants received standard formula (SF:2.2 g protein/100 kcal; n = 83) or low-protein formulas with α-lac-enriched whey (α-lac-EW;1.75 g protein/100 kcal; n = 82) or CGMP-reduced whey (CGMP-RW;1.76 g protein/100 kcal; n = 80) from 2 to 6 months. Breast-fed infants (BF; n = 83) served as reference. Except between 4 and 6 months, when weight gain did not differ between α-lac-EW and BF (p = 0.16), weight gain was higher in all formula groups compared to BF. Blood urea nitrogen did not differ between low-protein formula groups and BF during intervention, but was lower than in SF. Essential amino acids were similar or higher in α-lac-EW and CGMP-RW compared to BF. Conclusion: Low-protein formulas enriched with α-lac-enriched or CGMP-reduced whey supports adequate growth, with more similar weight gain in α-lac-enriched formula group and BF, and with metabolic profiles closer to that of BF infants.

Eating Frequency in European Children from 1 to 96 Months of Age: Results of the Childhood Obesity Project Study

We aimed to investigate the eating frequency (EF) in children over age, and examined the influence of country, sex, feeding mode and weight status on EF. We used the dietary data of the Childhood Obesity Project, which comprised European children from five countries. Dietary data of 3-days weighed and estimated records were available monthly from 1 to 9 and at 12-, 24-, 36-, 48-, 60-, 72- and 96-months old. Generalized additive mixed effects models were used to estimate EF trajectories with EF as outcome and applying age splines. Additionally, the models were further adjusted for country, feeding mode, sex or weight status. Data from 1244 children were analysed. EF was highest at 1 month with on average 7.3 ± 1.9 feeds per day, and fell to 5.1 ± 1.1 eating occasions at the age 96 months. Night feeding was similarly often than day feeding at 1 month but declined thereafter. Significant differences in EF were observed between countries (p < 0.05), with the highest EF in Poland, and between infant feeding modes, with a higher EF in breastfed than non-breastfed infants (p < 0.05). Sex and body weight were not associated with EF. Despite the importance of EF towards total energy intake, no association with weight status was found.

Effect of Protein Intake Early in Life on Kidney Volume and Blood Pressure at 11 Years of Age

High protein intake has been associated with kidney hypertrophy, which is usually reversible; however, when it occurs early in life, it could lead to cell programming with a long-lasting effect. This study aimed to assess whether higher protein ingestion early in life has a persistent effect on kidney volume at 11 years of age, as well as its influence on blood pressure. This is a secondary analysis of a randomized control trial that compared the growth of infants fed with a higher-protein formula versus those fed with a lower-protein formula, with a control group of breastfed infants. Renal ultrasound and anthropometric measurements were assessed at 6 months and 11 years of age. At 11 years, urinary protein, albumin and creatinine, and blood pressure were measured in 232 children. Feeding with a higher-protein formula was associated with a larger kidney volume (β = 8.71, 95%CI 0.09-17.33, p = 0.048) and higher systolic blood pressure (β = 3.43, 95%CI 0.78-6.08, p = 0.011) at 11 years of age. Microalbuminuria was detected in 7% of the patients, with no differences among groups (p = 0.56). The effect of increased protein ingestion early in life may condition kidney volume and blood pressure in later childhood.

Distribution of energy and macronutrient intakes across eating occasions in European children from 3 to 8 years of age: The EU Childhood Obesity Project Study

PURPOSE

We aimed to characterize the distribution of energy and macronutrient intakes across eating occasions (EO) in European children from preschool to school age.

METHODS

Data from 3-day weighed food records were collected from children at ages 3, 4, 5, 6 and 8 years from Belgium, Germany, Italy, Poland and Spain. Food intakes were assigned to EO based on country-specific daytimes for breakfast, lunch, supper and snacks (morning, afternoon). The average energy and nutrient intakes were expressed as percentage of total energy intake (%E). Nutrients were additionally expressed as percentage per EO (%E_EO). Foods were assigned to food groups; variation in intake was calculated via coefficient of variation (CV). We analyzed age trends in diurnal intake using mixed-effects beta regression.

RESULTS

The 740 healthy children included in the analysis consumed the largest proportion of daily energy at lunch (31%E ± 8, M ± SD) and supper (26%E ± 8), followed by breakfast (19%E ± 7) and snacks [afternoon (16%E ± 8); morning (8%E ± 7)], with the most variable intake at morning snack (CV = 0.9). The nutrient composition at lunch and supper was highest for fat (36 ± 9%E_Lunch; 39 ± 11%E_Supper) and protein (18 ± 5%E_Lunch; 18 ± 6%E_Supper) and at breakfast and snacks for carbohydrates (54 ± 12%E_Breakfast; 62 ± 12%E_Snacks). High-sugar content foods were consumed in relatively large proportions at breakfast and snacks. Food intakes varied significantly with age, with lower snack intakes at later ages (p < 0.001).

CONCLUSION

Possibly unhealthy EOs with high-fat intakes and high-sugar-content foods were observed. Changes in nutrient composition of EOs may be beneficial for health.

TRIAL REGISTRY

ClinicalTrials.gov: NCT00338689; 19/June/2006.

Effects of a Novel Infant Formula on Weight Gain, Body Composition, Safety and Tolerability to Infants: The INNOVA 2020 Study

Exclusive breastfeeding is recommended for the first six months of life to promote adequate infant growth and development, and to reduce infant morbidity and mortality. However, whenever some mothers are not able to breastfeed their infants, infant formulas mimicking human milk are needed, and the safety and efficacy of each formula should be tested. Here, we report the results of a multicenter, randomized, blinded, controlled clinical trial that aimed to evaluate a novel starting formula on weight gain and body composition of infants up to 6 and 12 months, as well as safety and tolerability. For the intervention period, infants were divided into three groups: group 1 received formula 1 (Nutribén® Innova 1 (Alter Farmacia S.A., Madrid, Spain) or INN (n = 70)), with a lower amount of protein, a lower casein to whey protein ratio by increasing the content of α-lactalbumin, and a double amount of docosahexaenoic acid/arachidonic acid than the standard formula; it also contained a thermally inactivated postbiotic (Bifidobacterium animalis subsp. lactis, BPL1TM HT). Group 2 received the standard formula or formula 2 (Nutriben® Natal (Alter Farmacia S.A., Madrid, Spain) or STD (n = 70)) and the third group was exclusively breastfed for exploratory analysis and used as a reference (BFD group (n = 70)). During the study, visits were made at 21 days and 2, 4, 6, and 12 months of age. Weight gain was higher in both formula groups than in the BFD group at 6 and 12 months, whereas no differences were found between STD and INN groups either at 6 or at 12 months. Likewise, body mass index was higher in infants fed the two formulas compared with the BFD group. Regarding body composition, length, head circumference and tricipital/subscapular skinfolds were alike between groups. The INN formula was considered safe as weight gain and body composition were within the normal limits, according to WHO standards. The BFD group exhibited more liquid consistency in the stools compared to both formula groups. All groups showed similar digestive tolerance and infant behavior. However, a higher frequency of gastrointestinal symptoms was reported by the STD formula group (n = 291), followed by the INN formula (n = 282), and the BFD groups (n = 227). There were fewer respiratory, thoracic, and mediastinal disorders among BFD children. Additionally, infants receiving the INN formula experienced significantly fewer general disorders and disturbances than those receiving the STD formula. Indeed, atopic dermatitis, bronchitis, and bronchiolitis were significantly more prevalent among infants who were fed the STD formula compared to those fed the INN formula or breastfed. To evaluate whether there were significant differences between formula treatments, beyond growth parameters, it would seem necessary to examine more precise health biomarkers and to carry out long-term longitudinal studies.

A cross-sectional study of infant feeding practices in Vietnamese-born mothers living in Australia

BACKGROUND

Infant feeding practices are a key modifiable risk factor for childhood overweight and obesity; and important for lifelong health and wellbeing. Despite the growing Australian immigrant population, it is unclear how infant feeding practices may differ between ethnicities living in Australia. Few studies have examined the infant feeding practices of Vietnamese mothers who migrate and give birth to infants in Australia - termed Vietnamese-born mothers. The aim of this study was to examine differences in infant feeding practices (breastfeeding, formula feeding and complementary feeding (other fluids and solids)) in Vietnamese-born mothers compared with Australian-born mothers living in Australia.

METHOD

This study analysed the Australian National Infant Feeding Survey dataset (2010-11), a large national cross-sectional survey measuring feeding practices of infants aged 0-24 months old. Infant feeding practices of Vietnamese-born mothers (n = 261) and a random sub-sample of Australian-born mothers (n = 261) were compared. Associations between ethnicity and infant feeding practices were examined through logistic and linear regression adjusting for maternal age, socioeconomic status, body mass index (BMI) at start of pregnancy, infant age at survey completion and parity. Compliance with the Australian national infant feeding guidelines was also assessed.

RESULTS

Compliance with infant feeding guidelines was low, with differences in infant feeding practices between groups. At the time of survey completion, when infants were on average 7.2 months old, compared with infants of Australian-born mothers, infants to Vietnamese-born mothers were significantly younger when first exposed to fruit juice (b = -2.41, 95%CI: -4.54- -0.28); less likely to be exposed to solids (AOR: 0.15, 95%CI: 0.05-0.44) and more likely to be exposed to formula milks (AOR: 2.21, 95%CI: 1.10-4.43); toddler milks (AOR: 16.72, 95%CI: 3.11-90.09) and fruit juice (AOR: 2.37, 95%CI: 1.06-5.32) (p < 0.05).

CONCLUSION

Low adherence with breastfeeding (low breastfeeding and high infant formula use) and other fluids (toddler milks and fruit juice) recommendations outlined by the Australian infant feeding guidelines were observed in this group of Vietnamese-born mothers. To optimise feeding and growth in Vietnamese-Australian children, culturally appropriate infant feeding support targeting breastfeeding durations, reducing reliance on infant formula, and reducing inappropriate introduction to other fluids should be the focus of infant feeding promotion within these mothers.

Different protein intake in the first year and its effects on adiposity rebound and obesity throughout childhood: 11 years follow-up of a randomized controlled trial

BACKGROUND AND OBJECTIVES

Infant feeding affects child growth and later obesity risk. We examined whether protein supply in infancy affects the adiposity rebound, body mass index (BMI) and overweight and obesity up to 11 years of age.

METHODS

We enrolled healthy term infants from five European countries in a double blind randomized trial, with anticipated 16 examinations within 11 years follow-up. Formula-fed infants (n = 1090) were randomized to isoenergetic formula with higher or lower protein content within the range stipulated by EU legislation in 2001. A breastfed reference group (n = 588) was included. Adiposity rebound and BMI trajectories were estimated by generalized additive mixed models in 917 children, with 712 participating in the 11 year follow-up.

RESULTS

BMI trajectories were elevated in the higher compared to the lower protein group, with significantly different BMI at adiposity rebound (0.24 kg/m², 0.01-0.47, p = 0.040), and an increased risk for overweight at 11 years (adjusted Odds Ratio 1.70; 1.06-2.73; p = 0.027) but no significant difference for obesity (adjusted Odds Ratio 1.47; 0.66-3.27). The two formula groups did not differ in the timing of adiposity rebound, but all children with obesity at 11 years had an early adiposity rebound before four years.

CONCLUSIONS

Compared to conventional high protein formula, feeding lower protein formula in infancy lowers BMI trajectories up to 11 years and achieves similar BMI values at adiposity rebound as observed in breastfed infants.

Time of Dietary Energy and Nutrient Intake and Body Mass Index in Children: Compositional Data Analysis from the Childhood Obesity Project (CHOP) Trial

Meal timing is suggested to influence the obesity risk in children. Our aim was to analyse the effect of energy and nutrient distributions at eating occasions (EO), including breakfast, lunch, supper, and snacks, on the BMI z-score (zBMI) during childhood in 729 healthy children. BMI and three-day dietary protocols were obtained at 3, 4, 5, 6, and 8 years of age, and dietary data were analysed as the percentage of the mean total energy intake (TEI; %E). Intakes at EOs were transformed via an isometric log-ratio transformation and added as exposure variables to linear mixed-effects models. Stratified analyses by country and recategorization of EOs by adding intake from snacks to respective meals for further analyses were performed. The exclusion of subjects with less than three observations and the exclusion of subjects who skipped one EO or consumed 5% energy or less at one EO were examined in sensitivity analyses. Around 23% of the children were overweight at a given time point. Overweight and normal-weight children showed different distributions of dietary intakes over the day; overweight children consumed higher intakes at lunch and lower intakes of snacks. However, no significant effects of timing of EOs on zBMI were found in regression analyses.

Effect of maternal smoking during pregnancy on child blood pressure in a European cohort

Hypertension is a public health issue that can have its origin in the early phases of development. Maternal smoking during pregnancy (MSDP) could play a role in offspring's cardio-metabolic programming. To assess the relationship between MSDP and later blood pressure (BP) in children we conducted a secondary analysis of a randomized dietary intervention trial (EU-Childhood Obesity Project). Healthy term infants with normal birth weight were recruited during the first 8 weeks of life in 5 European countries and followed until 11 years of age. Data on MSDP was collected at recruitment. BP and anthropometry were assessed at 11 years of age. Children were classified according to AAP guidelines as normal BP: BP < 90th percentile; high BP: ≥ 90th percentile with the subset of children having BP > 95th percentile categorized as hypertensive. Out of 572 children, 20% were exposed to MSDP. At 11 years, 26.8% had BP over the 90th centile. MSDP beyond 12 weeks of gestation was associated with higher systolic BP percentile (adjusted B 6.935; 95% CI 0.454, 13.429; p = 0.036) and over twofold increase likelihood of hypertension (OR 2.195; 95% CI 1.089, 4.423; p = 0.028) in children at 11 years. MSDP was significantly associated with later BP in children.

Quantity and Source of Protein during Complementary Feeding and Infant Growth: Evidence from a Population Facing Double Burden of Malnutrition

BACKGROUND

While high protein intake during infancy may increase obesity risk, low qualities and quantities of protein contribute to undernutrition. This study aimed to investigate the impact of the amount and source of protein on infant growth during complementary feeding (CF) in a country where under- and overnutrition co-exist as the so-called the double burden of malnutrition.

METHODS

A multicenter, prospective cohort was conducted. Healthy term infants were enrolled with dietary and anthropometric assessments at 6, 9 and 12 months (M). Blood samples were collected at 12M for IGF-1, IGFBP-3 and insulin analyses.

RESULTS

A total of 145 infants were enrolled (49.7% female). Animal source foods (ASFs) were the main protein source and showed a positive, dose-response relationship with weight-for-age, weight-for-length and BMI z-scores after adjusting for potential confounders. However, dairy protein had a greater impact on those parameters than non-dairy ASFs, while plant-based protein had no effect. These findings were supported by higher levels of IGF-1, IGFBP-3 and insulin following a higher intake of dairy protein. None of the protein sources were associated with linear growth.

CONCLUSIONS

This study showed the distinctive impact of different protein sources during CF on infant growth. A high intake of dairy protein, mainly from infant formula, had a greater impact on weight gain and growth-related hormones.

Infant Feeding Choices during the First Post-Natal Months and Anthropometry at Age Seven Years: Follow-Up of a Randomized Clinical Trial

The Belgrade–Munich Infant Milk Trial (BeMIM) randomized healthy term infants into either a protein-reduced intervention infant formula (IF) group, with an α-lactalbumin-enriched whey and long-chain polyunsaturated fatty acids, or a control infant formula (CF) group. A non-randomized breastfed group (BF) was studied for reference. We assessed the long-term effects of these infant feeding choices on growth measures until the age of seven years. Weight, standing height, head circumference, and percent body fat (using skinfolds and bioelectrical impedance) were determined with standardized methods. A total of 161 children out of the 256 completers of the initial study (63%) participated in the seven-year follow-up. Children in the three study groups did not differ in their anthropometric measures, including body mass index (IF 16.1 ± 2.6, CF: 15.6 ± 1.7, BF: 15.6 ± 2.5 kg/m², mean ± SD). IGF-1 serum concentrations determined at the age of 4 months contributed to explaining the variances in weight (p = 0.001), height (p = 0.001) and BMI (p = 0.035) z-scores at the age of seven years, whereas insulin levels at four months did not. Different feeding choices during the first four months of life leading to higher energy efficiency and increased growth with IF did not affect later growth outcomes at an early school age. Diet-induced modulation of IGF-1 in the first months of life may have lasting programming effects on later growth.

Body Composition in Adolescent PKU Patients: Beyond Fat Mass

There is a lack of evidence on the impact on body composition of high protein intake and types of protein substitutes in PKU patients—particularly in adolescents, who are more inclined to dietary transgressions. In this observational, cross-sectional study, PKU patients were observed during prepubertal age (p) or after the pubertal spurt (P), assessing body composition and bone quality and correlating these parameters with dietary compliance and types of protein substitutes. Anthropometric and dietary data were evaluated together with bioelectrical impedance analysis (BIA), quantitative ultrasound (QUS) and branched-chain amino acids (BCAAs). A total of 36 patients (16 males, 17 prepubertal and 19 post-pubertal; mean ± SD age 11.4 ± 3.9 years) were included. A higher BMI was observed in adolescents (p-value: 0.018). The BIA revealed a significant increase in total body water (TBW) and muscle mass (MM) in P subjects either compliant (p-value: 0.001) or non-compliant with the diet (p-value: 0.001). MM content correlated with increased Phe intake (r = 0.63; p < 0.001). In the subgroup of five patients taking L-AAs and glycomacropeptides (GMPs), BCAA values tended to be lower than those taking only L-AA mixtures, with a significant trend for valine. Maintenance of body composition parameters within the normal range—for both fat and muscle mass—and levels of BCAAs can be helpful in reducing the risk of becoming overweight in adulthood. Further studies are needed to confirm these findings.

Association of dietary macronutrient intake with adiposity during childhood according to sex: Findings from the generation XXI birth cohort

BACKGROUND/OBJECTIVES

Few studies have assessed the independent and longitudinal effects of each macronutrient intake on adiposity throughout childhood. We aimed to prospectively assess the independent associations between each macronutrient intake at 4, 7, and 10 years (protein, carbohydrates, fat, and fibre) and each measure of adiposity from 7 to 10 years of age by sex.

METHODS

Data from the population-based birth cohort Generation XXI was used (n = 3999). At 4, 7, and 10 years old, dietary, anthropometric and sociodemographic data were collected. The dietary intake of the children was evaluated by a validated food frequency questionnaire. Age- and sex-specific body mass index z-scores (zBMI), percentage of body fat (%FM) from bio-impedance, and waist-to-hip ratio (Whr) were used as measures of adiposity. Path analysis tested the independent associations between each macronutrient intake (protein, carbohydrates, fat, and fibre) and each measure of adiposity from 7 to 10 years of age.

RESULTS

In fully adjusted models, an increase in energy from fibre intake at the age of 7 was associated with lower zBMI at the same age (β = -0.073; 95%CI [-0.127,-0.019]) and at 10 years (β = -0.083; 95%CI [-0.137,-0.029]). Similar results were found for %FM and Whr, and in each sex separately. At the age of 10, an increase in energy from fibre intake was associated with lower %FM and Whr, while an increase in energy from protein was associated with an increase in Whr (β = 0.061; 95%CI [0.014, 0.107]).

CONCLUSIONS

Our study supports the protective effect of fibre intake on adiposity development during childhood in both sexes.

Considerations for the translation of nutrient recommendations as dietary plans for infants, children, and adolescents as reported in Italian Guidelines for healthy eating

Healthy eating in childhood and adolescence is important for proper growth and development and to establish a healthy foundation for future dietary habits. This paper aims to describe the elaboration of dietary plans for pediatric ages highlighting critical points related to the application of the Italian nutrient recommendations. National databases on food composition data were used to compile the dietary plans. Starting from the definition of serving size for adults, the suggested portion size for pediatric ages was shaped to produce appropriate dietary plans according to the different classes of age. Items from “cereals and derivatives,” “milk,” “fruit,” “vegetables,” “olive oil,” and “water” groups were included daily. Pizza was included once a week. Sweets and snacks were gradually introduced, once a week in infants and up to five times a week in adolescents. Legumes were provided three times a week, as a source of vegetable and sustainable proteins. The main critical aspect of the dietary plans was related to the monotony, especially for snacks and breakfasts. This work demonstrated the limits of the translation of Italian nutrient recommendations into dietary plans for pediatric age groups. Keeping the protein intake in the recommended range of 8–12% of daily energy resulted in inadequate provision of calcium and iron. Other critical points were the reference values for body weight and physical activity. The proposed dietary plans are adequate with regard to food composition, the intake of energy and several nutrients, and in terms of food selection. However, their implementations require action, information, and advocacy.

Low-Protein Infant Formula and Obesity Risk

Infant formulas have been designed to mimic human milk for infants who cannot be breastfed. The overall goal is to establish similar functional outcomes to assure optimal growth, development, maturation of the immune system, and programming of the metabolic system. However, after decades of improving infant formula, growth patterns and body composition development are still different in formula-fed infants compared to breastfed infants, which could contribute to an increased risk of obesity among formula-fed infants. It has been hypothesized that the lower protein concentration of breast milk compared to infant formula influences infants’ growth and body composition. Thus, several trials in formula-fed infants with different protein intake levels have been performed to test this hypothesis. In this review, we discuss the current evidence on low-protein infant formula and obesity risk, including future perspectives and implications.

Infant intakes of human milk branched chain amino acids are negatively associated with infant growth and influenced by maternal body mass index

BACKGROUND

Branched-chain amino acids (BCAAs: isoleucine, leucine, and valine) and aromatic amino acids (AAAs: phenylalanine and tyrosine) are hypothesized to influence early-life obesity risk.

OBJECTIVE

To assess HM free amino acid (AA) concentrations and infant intakes of HM AAs from women with obesity (OB) compared to those with normal weight (NW) and determine the relationships between HM AA consumption and infant growth.

METHODS

HM samples were collected at 0.5 (n = 151), 2 (n = 129), and 6 (n = 93) months postpartum from mothers with NW (body mass index [BMI] = 18.5-24.9 kg/m² ) and OB (BMI > 30 kg/m² ). HM AAs were quantified via mass spectrometry. Infant HM intake, anthropometrics and body composition were assessed. Linear mixed-effects models (LMEM) examined the relationships between maternal BMI and HM AA intakes, and HM AA intake and infant growth over the first 6 months postpartum after adjusting for maternal and infant characteristics.

RESULTS

Maternal BMI was positively associated with infant intakes of isoleucine, leucine, and AAAs across timepoints. HM AA intakes were positively associated with weight-for-length z-score, fat mass index, and fat-free mass index in infants (p < 0.05).

CONCLUSIONS

Maternal BMI led to differences in HM AA composition, which was associated with infant body composition.

Early life programming of health and disease: the long-term consequences of obesity in pregnancy: a narrative review

The prevalence of overweight and obesity is rising in all parts of the world and among young women it presents a very clear danger during pregnancy. Women who are overweight or who gain excessive weight during pregnancy are at greater risk of complications in pregnancy and labour, and are more likely to lose their child to stillbirth, or themselves die during pregnancy. This narrative review considers the evidence that in addition to increasing risk of poor pregnancy outcomes, obesity has the capacity to programme fetuses to be at greater risk of cardiometabolic disorders later in life. An extensive body of evidence from prospective and retrospective cohorts, and record linkage studies demonstrates associations of maternal obesity and/or gestational diabetes with cardiovascular disease, type-1 and type-2 diabetes. Studies in animals suggest that these associations are underpinned by adaptations that occur in fetal life, which remodel the structures of major organs including the brain, kidney and pancreas. This article is protected by copyright. All rights reserved.

Neither Incretin or Amino Acid Responses, nor Casein Content, Account for the Equal Insulin Response Following Iso-Lactose Loads of Natural Human and Cow Milk in Healthy Young Adults

Human milk contains <50% less protein (casein) than cow milk, but is equally effective in insulin secretion despite lower postingestion hyperaminoacidemia. Such potency of human milk might be modulated either by incretins (glucagon-like polypeptide-1,GLP-1); glucose-inhibitory-polypeptide, GIP), and/or by milk casein content. Healthy volunteers of both sexes were fed iso-lactose loads of two low-protein milks, i.e., human [Hum] (n = 8) and casein-deprived cow milk (Cow [↓Cas]) (n = 10), as well as loads of two high-protein milks, i.e., cow (n = 7), and casein-added human-milk (Hum [↑Cas]) (n = 7). Plasma glucose, insulin, C-peptide, incretins and amino acid concentrations were measured for 240′. All milks induced the same transient hyperglycemia. The early [20′−30′] insulin and C-peptide responses were comparable among all milk types apart from the low-protein (Cow [↓Cas]) milk, where they were reduced by <50% (p < 0.05 vs. others). When comparing the two high-protein milks, GLP-1 and GIP [5’−20’] responses with the (Hum [↑Cas]) milk were lower (by ≈2−3 fold, p < 0.007 and p < 0.03 respectively) than those with cow milk, whereas incretin secretion was substantially similar. Plasma amino acid increments largely reflected the milk protein content. Thus, neither casein milk content, nor incretin or amino acid concentrations, can account for the specific potency of human milk on insulin secretion, which remains as yet unresolved.

Comprehensiveness of infant formula and bottle feeding resources: A review of information from Australian healthcare organisations

The use of infant formula is widespread internationally. In Australia, 55% of infants receive formula before 6 months of age, with higher rates among disadvantaged communities. Infant formula use can contribute to childhood overweight and obesity, through formula composition and feeding behaviours, such as adding cereal to bottles and parental feeding style. While information abounds to promote and support breastfeeding, formula‐feeding parents report a paucity of advice and support; many rely on formula packaging for information. This study systematically searched and reviewed online resources for infant formula and bottle feeding from Australian governments, health services, hospitals, and not‐for‐profit parenting organisations. A comprehensive search strategy located 74 current resources, mostly for parents. Researchers evaluated the resources against best practice criteria derived from Australian government and UNICEF guidelines on six topics. They assessed how comprehensively the resources addressed each topic and whether the resources provided all the information necessary for parents to understand each topic. The mean ‘comprehensiveness’ rating for topics across all resources was 54.36%. However, some topics were addressed more fully than others. Information on ‘discussing infant formula with health workers’ and on ‘preparing infant formula’ was more frequently accurate and comprehensive. However, there was much less comprehensive information on ‘using infant formula’, including amounts of formula to feed, use of bottle teats, appropriate bottle‐feeding practice and responsiveness to infant satiety cues. Over half the resources were written at an acceptable reading level.

Insufficient formula‐feeding support from health services can lead to parents relying on formula packaging or other commercial information.

Most formula‐feeding resources from Australian healthcare organisations focus on preparing infant formula and using infant formula. However, comprehensiveness of information varies—on average, information on preparing infant formula was more comprehensive than that on using infant formula.

Many resources do not address responsive bottle‐feeding practices, which impacts risk of infant overweight and obesity.

The Australian government infant feeding guidelines should be revised to include more comprehensive best‐practice formula‐feeding recommendations; subsequently, this should be reflected in formula‐feeding information from health organisations.

Usual Nutrient Intake Distribution and Prevalence of Inadequacy among Australian Children 0-24 Months: Findings from the Australian Feeding Infants and Toddlers Study (OzFITS) 2021

(1) Background: Breastmilk provides all the nutrition an infant requires between 0−6 months. After that, complementary foods are needed to meet the child’s increasing energy and nutrient requirements. Inadequate energy and nutrient intake may lead to growth faltering, impaired neurodevelopment, and increased disease risk. While the importance of early life nutrition is well recognized, there are few investigations assessing the nutritional adequacy of Australian children <24 months. Here, we describe usual energy and nutrient intake distributions, including the prevalence of inadequate intakes and exceeding the upper limit (UL), in a national sample of Australian children 6− 24 months and infants < six months who had commenced solids and/or formula. (2) Methods: Dietary intakes were assessed using a one-day food record for 976 children with a repeat one-day record in a random subset. (3) Results: Based on the Nutrient Reference Values for Australia and New Zealand, children’s intakes were above the Adequate Intake or Estimated Average Requirement for most nutrients. Exceptions were iron and zinc where the prevalence of inadequacy was estimated to be 90% and 20%, respectively, for infants aged 6−11.9 months. Low iron intake was also observed in one quarter of toddlers 12−24 months. On average, children consumed 10% more energy than predicted based on Estimated Energy Requirements, and ~10% were classified as overweight based on their weight for length. One third of toddlers exceeded the tolerable upper limit for sodium and consumed > 1000 mg/day. Of the children under six months, 18% and 43% exceeded the UL for vitamin A (retinol) and zinc. (4) Conclusions: Compared to nutrient reference values, diets were sufficient for most nutrients; however, iron was a limiting nutrient for infants aged 6−11.9 months and toddlers 12−24 months potentially putting them at risk for iron deficiency. Excessive sodium intake among toddlers is a concern as this may increase the risk for hypertension.

Burden of Early Life Obesity and Its Relationship with Protein Intake in Infancy: The Middle East Expert Consensus

Adequate nutrition in early life is proposed to shape a child's future health by launching the growth trajectory in the proper direction, which helps to avoid negative metabolic programming effects. Protein intake during infancy and early childhood is of great importance, as it plays a key role in infant metabolic programming and the future risk of obesity. Breastfeeding provides the best nutrition in early life, with many benefits tailored for the baby, including the appropriate quantity and quality of proteins. Considering the high prevalence of childhood, and subsequent adult, obesity in the region, a virtual Middle East expert consensus meeting was held to discuss an effective approach for managing childhood obesity. Leading pediatric experts from Bahrain, Egypt, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates participated in the meeting. The experts discussed, debated, and agreed on certain directions, including the importance of educating parents, endorsing breastfeeding, and ensuring optimum quantity and quality intake of proteins in early life. This expert consensus may serve as the starting point for healthcare professionals in the region who are interested in shaping a healthy future for the generations to come.

Detailed knowledge of maternal and infant factors and human milk composition could inform recommendations for optimal composition

Breastfeeding is best for infants, but quantitative associations between specific milk components and infant biomarkers remain unclear. Methodological limitations include missing milk volume intake, variable milk composition and that standardised, fasted state blood sampling is impossible in infants. Milk protein and fat content appear marginally related to infant serum amino acid and phospholipid concentrations, with some association between milk fatty acid composition and lipid species levels. CONCLUSION: Detailed simultaneous examinations of maternal factors, milk composition and infant biomarkers or outcomes could identify the mechanistic basis of human milk effects and help develop dietary recommendations for optimal human milk composition.