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.

Correction: Otten et al. Safety and Suitability of an Infant Formula Manufactured from Extensively Hydrolysed Protein in Healthy Term Infants. Nutrients 2023, 15, 1901.

In the original publication [...].

Safety and Suitability of an Infant Formula Manufactured from Extensively Hydrolysed Protein in Healthy Term Infants.

We aimed to demonstrate that healthy term infants experience noninferior growth with infant formula manufactured from extensively hydrolysed whey protein (eHF) compared to intact cow's milk protein (control formula, CF). This prospective, randomised, double-blind, parallel-group, controlled, multicentre trial included healthy term infants who were exclusively formula-fed. Infants ≤ 25 days of age received eHF or CF for at least three months up to 120 days of age, with a follow-up until 180 days of age. A reference group included exclusively breastfed infants (BF). Of 318 infants randomised, 297 (148 CF, 149 eHF) completed the study per protocol. Weight gain up to 120 days of age was noninferior (margin -3.0 g/day) in eHF (28.95 (95% CI: 27.21; 30.68) g/day) compared to CF (28.85 (95% CI: 27.10; 30.61) g/day) with a difference in means of 0.09 g/day and a lower limit of the one-sided 97.5% CI of -0.86 g/day (p < 0.0001 for noninferiority testing). Weight gain remained comparable during follow-up. Further anthropometric parameters did not differ between the infant formula groups throughout the study. Growth was comparable in BF. No relevant safety issues were observed. To conclude, eHF meets infant requirements for adequate growth during the first six months of life and can be considered safe and suitable.

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.

Allergic diseases in infancy II-oral tolerance and its failure.

OBJECTIVE: The early window of opportunity describes the timeframe after birth in which essential interactions of the immune system and the newly developing microbiota take place. The infant's immune system has to be reactive to invading pathogens and at the same time tolerant to dietary antigens. If the mechanisms of defense and tolerance induction are disturbed, the risk of infections or allergies is increased. METHOD: This is a narrative review of the recently published information on the topic of neonatal intestinal development and mechanisms of oral tolerance and summarizes the discussions and conclusions from the 8th Human Milk Workshop. RESULTS: The early postnatal period sets the stage for life-long host-microbiome interaction. In this early phase, specific developmental mechanisms ensure physiologic interaction with the developing microbiota. Innate and adaptive immune cells interact in a concerted way to induce and uphold oral tolerance. Factors in human milk can support this induction of tolerance and simultaneously protect against infection and allergy development. CONCLUSION: Understanding the developmental mechanisms in this early phase of immune system development is the first step to develop strategies of pathology prevention. As human milk protects the infant from infections, and aids to develop a tolerogenic immune response, further knowledge on the protective factors in human milk and their effect on the immune system is required.

Allergic diseases in infancy: I - Epidemiology and current interpretation.

Objective: Among non-communicable diseases, the prevalence of allergic diseases has increased significantly in the new millennium. The increase of allergic diseases is linked to the changing environment of infants. Methods: This narrative review summarizes the discussions and conclusions from the 8th Human Milk Workshop. Information from the fields of pediatrics, epidemiology, biology, microbiology, and immunology are summarized to establish a framework describing potential avenues for the prevention of allergic diseases in the future. Results: Several environmental circumstances are linked to the development of allergic diseases. While cesarean section is increasing the risk of allergies, early childhood exposure to a farm environment has a protective effect. From their analysis, nutritive and non-nutritive factors influencing the allergy risk in later life have been identified. The effect of breastfeeding on food allergy development is non-univocal. Human milk components including immunoglobulins, cytokines, and prebiotics have been indicated as important for allergy prevention. Conclusion: Many factors linked to the western lifestyle have been associated with the development of allergic diseases. This suggests several theories that may serve as a basis for new protective interventions. While it is indubitable that mother's milk protects from infectious diseases, its role in the prevention of allergic diseases is to be elucidated.

Early-Life Metabolic and Hormonal Markers in Blood and Growth until Age 2 Years: Results from a Randomized Controlled Trial in Healthy Infants Fed a Modified Low-Protein Infant Formula.

BACKGROUND: High protein intake in early life is associated with an increased risk of childhood obesity. Dietary protein intake may be a key mechanistic modulator through alterations in endocrine and metabolic responses. OBJECTIVE: We aimed to determine the impact of different protein intake of infants on blood metabolic and hormonal markers at the age of four months. We further aimed to investigate the association between these markers and anthropometric parameters and body composition until the age of two years. DESIGN: Term infants received a modified low-protein formula (mLP) (1.7 g protein/100 kcal) or a specifically designed control formula (CTRL) (2.1 g protein/100 kcal) until 6 months of age in a double blinded RCT. The outcomes were compared with a breast-fed (BF) group. Glucose, insulin, leptin, IGF-1, IGF-BP1, -BP2, and -BP3 levels were measured at the age of 4 months. Anthropometric parameters and body composition were assessed until the age of 2 years. Groups were compared using linear regression analysis. RESULTS: No significant differences were observed in any of the blood parameters between the formula groups (n = 53 mLP; n = 44 CTRL) despite a significant difference in protein intake. Insulin and HOMA-IR were higher in both formula groups compared to the BF group (n = 36) (p < 0.001). IGF-BP1 was lower in both formula groups compared to the BF group (p < 0.01). We found a lower IGF-BP2 level in the CTRL group compared to the BF group (p < 0.01) and a higher IGF-BP3 level in the mLP group compared to the BF group (p = 0.03). There were no significant differences in glucose, leptin, and IGF-1 between the three feeding groups. We found specific associations of all early-life metabolic and hormonal blood parameters with long-term growth and body composition except for IGF-1. CONCLUSIONS: Reducing protein intake by 20% did not result in a different metabolic profile in formula-fed infants at 4 months of age. Formula-fed infants had a lower insulin sensitivity compared to breast-fed infants. We found associations between all metabolic and hormonal markers (except for IGF-1) determined at age 4 months and growth and body composition up to two years of age.

Association of infant formula composition and anthropometry at 4 years: Follow-up of a randomized controlled trial (BeMIM study).

The relationships between nutrition, metabolic response, early growth and later body weight have been investigated in human studies. The aim of this follow-up study was to assess the long-term effect of infant feeding on growth and to study whether the infant metabolome at the age of 4 months might predict anthropometry at 4 years of age. The Belgrade-Munich infant milk trial (BeMIM) was a randomized controlled trial in which healthy term infants received either a protein-reduced infant formula (1.89 g protein/100 kcal) containing alpha-lactalbumin enriched whey and long-chain polyunsaturated fatty acids (LC-PUFA), or a standard formula (2.2 g protein/100 kcal) without LC-PUFA, focusing on safety and suitability. Non-randomized breastfed infants were used as a reference group. Of the 259 infants that completed the BeMIM study at the age of 4 months (anthropometry assessment and blood sampling), 187 children participated in a follow-up visit at 4 years of age. Anthropometry including weight, standing height, head circumference, and percent body fat was determined using skinfolds (triceps, subscapular) and bioelectrical impedance analysis. Plasma metabolite concentration, collected in samples at the age of 4 months, was measured using flow-injection tandem mass spectrometry. A linear regression model was applied to estimate the associations between each metabolite and growth with metabolites as an independent variable. At 4 years of age, there were no significant group differences in anthropometry and body composition between formula groups. Six metabolites (Asn, Lys, Met, Phe, Trp, Tyr) measured at 4 months of age were significantly associated with changes in weight-for-age z-score between 1 to 4 months of age and BMI-for-age z-score (Tyr only), after adjustment for feeding group. No correlation was found between measured metabolites and long-term growth (up to 4 years of age). No long-term effects of early growth patterns were shown on anthropometry at 4 years of age. The composition of infant formula influences the metabolic profile and early growth, while long-term programming effects were not observed in this study.

Hydrolyzed Formula With Reduced Protein Content Supports Adequate Growth: A Randomized Controlled Noninferiority Trial.

OBJECTIVE: A high protein content of nonhydrolyzed infant formula exceeding metabolic requirements can induce rapid weight gain and obesity. Hydrolyzed formula with too low protein (LP) content may result in inadequate growth. The aim of this study was to investigate noninferiority of partial and extensively hydrolyzed formulas (pHF, eHF) with lower hydrolyzed protein content than conventionally, regularly used formulas, with or without synbiotics for normal growth of healthy term infants. METHODS: In an European multi-center, parallel, prospective, controlled, double-blind trial, 402 formula-fed infants were randomly assigned to four groups: LP-formulas (1.9 g protein/100 kcal) as pHF with or without synbiotics, LP-eHF formula with synbiotics, or regular protein eHF (2.3 g protein/100 kcal). One hundred and one breast-fed infants served as observational reference group. As primary endpoint, noninferiority of daily weight gain during the first 4 months of life was investigated comparing the LP-group to a regular protein eHF group. RESULTS: A comparison of daily weight gain in infants receiving LPpHF (2.15 g/day CI -0.18 to inf.) with infants receiving regular protein eHF showed noninferior weight gain (-3.5 g/day margin; per protocol [PP] population). Noninferiority was also confirmed for the other tested LP formulas. Likewise, analysis of metabolic parameters and plasma amino acid concentrations demonstrated a safe and balanced nutritional composition. Energetic efficiency for growth (weight) was slightly higher in LPeHF and synbiotics compared with LPpHF and synbiotics. CONCLUSIONS: All tested hydrolyzed LP formulas allowed normal weight gain without being inferior to regular protein eHF in the first 4 months of life. This trial was registered at clinicaltrials.gov, NCT01143233.

Role of selected amino acids on plasma IGF-I concentration in infants.

PURPOSE: Insulin-like growth factor-I (IGF-I) is related to growth and its secretion is modified by protein intake in early infancy. We examined the relationship of dietary protein and circulating amino acids on plasma IGF-I levels and early growth. METHODS: Healthy formula-fed infants (n = 213) were randomly assigned to receive either a protein-reduced infant formula with alpha-lactalbumin-enriched whey and free tryptophan and phenylalanine (IF) or an isocaloric standard formula without free amino acids (CF) for the first 120 days of life. A group of breastfed (BF) infants was studied as a non-randomized reference cohort. Biochemical variables were measured shortly after birth (subpopulation) and at an age of 120 days. A path analysis was used to explore the relationship between IGF-I, insulin and amino acids. Results are derived from secondary analyses of a randomized controlled trial. RESULTS: Plasma concentrations of IGF-I at 120 days were significantly higher in IF than in CF infants [58.5 (15.0) vs. 53.7 (9.95) ng/mL; p = 0.020]. BF infants showed lower IGF-I concentrations of 41.6 (10.7) ng/mL. All amino acids but Thr and Cit had a more marked effect on insulin than on IGF-I level. Considering weight, sex and feeding group, Trp explained an equal percentage of variance of IGF-I and insulin (total R 2 12.5 % of IGF-I and 12.3 % of insulin), while branched-chain AA explained an up to twofold higher variance of insulin than IGF-I. Compared to CF, IF explained 18.9 % of the IGF-I level (p = 0.03), while for insulin no direct effect was detectable. CONCLUSION: Higher IGF-I concentrations and growth velocities in infants receiving protein-reduced IF indicate that the protein concentration of an infant formula alone does not control IGF-I levels and growth. Other components (e.g., selected amino acids) of infant formulae might control directly or indirectly via insulin influence IGF-I.

Phospholipid Species in Newborn and 4 Month Old Infants after Consumption of Different Formulas or Breast Milk.

INTRODUCTION: Arachidonic acid (AA) and docosahexaenoic acid (DHA) are important long-chain polyunsaturated fatty acids for neuronal and cognitive development and are ingredients of infant formulae that are recommended but there is no evidence based minimal supplementation level available. The aim of this analysis was to investigate the effect of supplemented AA and DHA on phospholipid metabolism. METHODS: Plasma samples of a randomized, double-blind infant feeding trial were used for the analyses of phospholipid species by flow-injection mass spectrometry. Healthy term infants consumed isoenergetic formulae (intervention formula with equal amounts of AA and DHA-IF, control formula without additional AA and DHA-CF) from the first month of life until the age of 120 days. A group of breast milk (BM) -fed infants was followed as a reference. RESULTS: The plasma profile detected in newborns was different from 4 month old infants, irrespective of study group. Most relevant changes were seen in higher level of LPC16:1, LPC20:4, PC32:1, PC34:1 and PC36:4 and lower level of LPC18:0, LPC18:2, PC32:2, PC36:2 and several ether-linked phosphatidylcholines in newborns. The sum of all AA and DHA species at 4 month old infants in the CF group showed level of 40% (AA) and 51% (DHA) of newborns. The supplemented amount of DHA resulted in phospholipid level comparable to BM infants, but AA phospholipids were lower than in BM infants. Interestingly, relative contribution of DHA was higher in ether-linked phosphatidylcholines in CF fed infants, but IF and BM fed infants showed higher overall ether-linked phosphatidylcholines levels. CONCLUSION: In conclusion, we have shown that infant plasma phospholipid profile changes remarkably from newborn over time and is dependent on the dietary fatty acid composition. A supplementation of an infant formula with AA and DHA resulted in increased related phospholipid species.

Energetic efficiency of infant formulae: a review.

Breast-fed and formula-fed infants differ in terms of nutrient intake, growth, and metabolic and endocrine responses. The energetic efficiency, i.e. the weight or length gain per 100 kcal of energy intake, of breast-fed infants is about 11% higher than the energetic efficiency of formula-fed infants. Only limited data is available on the influence of formula composition on the energetic efficiency of infant formulae. We conducted a review of controlled trials to identify the impact of the macronutrient composition of infant formulae on energetic efficiency. An electronic literature search was conducted in February 2014. Intervention trials that investigated the effect of an infant formula with a modified macronutrient composition and reported the weight, length, and nutritional intake of apparently healthy, term, fully formula-fed infants with a normal weight were included. Thirteen trials met the inclusion criteria. The results showed no effect of the total content of energy, carbohydrate, protein, or fat on energetic efficiency. In contrast, small increasing effects of higher glycemic carbohydrates on energetic efficiency were identified. Improved fat absorption via the use of palmitic acid at the sn-2 ester position of triacylglycerol increased the energetic efficiency by 11%. The quality of formula protein, specifically an increased whey-to-casein ratio, an increased α-lactalbumin content, or a higher tryptophan content increased the energetic efficiency by about 13%. We conclude that fat absorption and protein quality have the potential to modulate energetic efficiency and may contribute to the observed differences in growth and metabolism between breast-fed and formula-fed infants.

Infant formula composition affects energetic efficiency for growth: the BeMIM study, a randomized controlled trial.

BACKGROUND & AIMS: Protein source, macronutrient composition and content of long chain-polyunsaturated fatty acids (LC-PUFA) of infant formulae may influence infant growth. We aimed to assess the effect of a modified infant formula on growth. METHODS: In a randomized, double-blind trial, 213 healthy term infants consumed isoenergetic study formulae (intervention formula - IF, control formula - CF) from the first month of life until the age of 120 days. IF (1.89 g protein/100 kcal) contained α-lactalbumin (ALAB) and LC-PUFA, while CF (2.30 g protein/100 kcal) provided standard whey and no LC-PUFA. Anthropometry and dietary intake were regularly assessed. A venous blood sample was obtained on day 120. RESULTS: Both formulae were well-accepted without significant differences in health related observations. Weight gain was not statistically different between formula groups (IF: 30.2 ± 6.3 vs. CF: 28.3 ± 6.5 g/day, mean ± SD, P = 0.06). Length gain was higher in IF (0.11 ± 0.02 vs. 0.10 ± 0.02 cm/day, P = 0.02). Energy intake from formula was higher in CF at 90 and 120 days (IF: 509 ± 117 and 528 ± 123 vs. CF: 569 ± 152 and 617 ± 169 kcal/day, P < 0.01). Protein intake in CF was significantly higher at each assessment. Growth per energy intake was higher in IF compared to CF for weight (6.45 ± 2.01 vs. 5.67 ± 2.21 g/100 kcal, P = 0.02) and length (0.23 ± 0.08 vs. 0.20 ± 0.08 mm/100 kcal, P = 0.04). CONCLUSIONS: The modified infant formula with reduced protein content with added ALAB and LC-PUFA, meets infant requirements of protein for adequate growth. The increased energetic efficiency of the new infant formula might result from improved protein composition by added ALAB. Apparently minor differences in composition can markedly affect energetic efficiency for growth. The study was registered at ClinicalTrials.gov (NCT01094080).

Nutritional evaluation of rapeseed protein compared to soy protein for quality, plasma amino acids, and nitrogen balance--a randomized cross-over intervention study in humans.

BACKGROUND & AIMS: Plant proteins such as rapeseed have received little attention for human nutrition due to their high level of antinutritive compounds. Today, newer technologies can eliminate such compounds. The present intervention study aimed to evaluate nutritional and physiological properties of two manufactured canola proteins with special focus on their bioavailability in humans. METHODS: 28 healthy male subjects (ø 25 years) consumed 30.0 g protein (canola protein isolate--CPI, canola protein hydrolyzate--CPH or soy protein isolate--SPI) in a randomized, double-blind, cross-over study. Blood samples were regularly drawn over the 8-h postprandial period and a 24-h urine sample was collected. RESULTS: True digestibility of the canola proteins determined in a separate rat assay showed 93.3% for CPI and 97.3% for CPH. In humans, consumption of either 30.0 g canola protein or soy protein mixed in a drink led to significant increases in plasma amino acids after 62.3 and 83.6 min, respectively. While the CPH produced an earlier response compared to CPI and SPI, total amino acid response (AUC for 8 h) was comparable between all interventions. The nitrogen balance between the three proteins tested showed no statistical differences. CONCLUSIONS: High digestibility of rapeseed protein was found in rats. In humans, this is the first intervention study showing rapeseed protein (both isolate and hydrolyzate) as having a high nutritional quality and can be considered to be as efficient as soy protein for a postprandial amino acid response. This trial was registered at ClinicalTrials.gov Identifier: NCT01481584.