Mum's the word

Attitudes to infant nutrition among health professionals and the wider population seem to suffer from a time-lag. Both groups appear to find it difficult to shift some very different sets of prejudices.Medical director at Nutricia UK Tahsin Yasin explains his perspective on this: "A lot of the existing dogma against infant formula goes back to the 1980s. But in fact, there have been massive advances when it comes to areas such as protein technology, fat content and prebiotics."

The industry, he says, has worked with the European Commission at Directive level to help bring down the protein density of formula. Owned by Danone since October last year, he adds, Nutricia itself aims to double its R&D budget.

Of course, this could be seen as furious back-pedalling in the face of very new, rather than outdated, evidence.

Atul Singhal is deputy director of the Medical Research Council (MRC) Childhood Nutrition Research Centre at the Institute of Child Health in London: "Formula feeding can encourage overfeeding, while breastfeeding is associated with slower patterns of growth. If the child puts on weight too quickly, the risk of obesity and cardiovascular conditions in later life increases."

At first, Singhal's team had to battle against some deeply-entrenched preconceptions. "When we started, we had a rough time because people were saying we should be giving young children more, not less, to eat." After all, David Barker's influential work at Southampton University in the early 1990s hypothesised a link between undernutrition in the womb (and in infancy), low birth weight, and later cardiovascular health problems.

Similar prejudices regarding weight gain in infants remain unshakeable in many parents. Health professionals report the pride many mums take in seeing their infants break upwards out of their centile weight growth curves. This is despite the fact that sustained, accelerated early weight gain is now considered an indicator of concern, rather than healthy development.

Working in Earnest​

Researchers are, no doubt, similarly concerned about growth patterns in project acronmyms, if not the projects themselves. Chief among these must be the EU's chubby EARNEST programme, blessed with the unlikely full name of EARly Nutrition programming - long-term Efficacy and Safety Trials, and fuelled with a high-protein 16.8M euro budget.

Running since 2005, and due to conclude in 2010, EARNEST brings together a wide range of sub-projects. As project manager Dr Julia Von Rosen of Munich University explains, trials span the obesity implications of formula feeding, the role of fish oil supplements in pregnancy, and everything in-between.

Despite broad acceptance among health professionals of the importance of breastfeeding up to six months, a variety of circumstances mean that mothers following this advice to the letter remain the exception rather than the rule.

Among EARNEST research partners, the Rowett Institute in Aberdeen, Scotland, has looked at areas including the impact of high- and low-protein diets on the foetus, and the impact of maternal deficiency in micronutrients such as iron, copper and zinc. Regarding the second of these areas, head of policy and scientific studies professor Harry McArdle points to further research issues. While the effect of different nutrient levels can be modelled, and the impact of supplementation can be investigated, there are no easy ways of measuring iron, copper or zinc status in humans, he explains.

Nonetheless, says McArdle, this area needs more work. "Over the next few years, we'll deduce why these micronutrients are having an effect. The ideal would be to be able to identify at-risk groups."

The value of prebiotics​

Among the ingredients firms participating in EARNEST, Beneo Orafti is keen to explore the value of prebiotics in infant nutrition. As with so many of the nutritional building blocks of breastmilk, the role of prebiotic oligosaccharides is indicative and inferred rather than conclusive. All the same, the potential for oligofructose and inulin to promote beneficial gut bacteria in infants is widely accepted.

While dairy-derived formula will never completely simulate - or replace - breastmilk, the challenge for many remains narrowing that gap. Irish-based Carbery emphasises the part played by hydrolysed whey proteins in increasing digestibility and decreasing the risk of an allergic reaction in the infant. Its Optipep range of proteins introduced three years ago includes variants with a high hydrolysis level, suitable for infant applications and offering an improved flavour profile.

Meanwhile, equally significant results are emerging from research into prenatal nutrition. Caroline Relton lectures in genetic epidemiology at the University of Newcastle in the UK. Her overlapping fields of research with ingredients such as folates illustrate the interrelations between the 'mums' and 'kids' side of the equation. And as a geneticist, her interest in nutritional research also highlights the multidisciplinary approach increasingly being taken in this area of nutrition programming.

In some areas at least, the influence of maternal health and prenatal nutrition on both the success of the birth itself and short- and long-term outcomes in the child is now taken for granted. Relton states: "Early foetal trials showed that with folate supplements, the likelihood of neural tube defects is radically reduced. And the healthier the maternal folate state, the more likely is a healthy birthweight."

Relton's particular interest is in the area of epigenetics, and the influence of processes such as methylation - the addition of methyl groups to the DNA molecule. As she explains: "You can change the landscape of the genome and affect how it passes information on in this and future generations."

On the post-natal side, her team at Newcastle is now looking at babies born pre-term, before 34 weeks, and the effect of different proteins on the molecular level.

This research overlap between pre- and post-natal nutrition is mirrored in the opportunities open to brand owners and ingredients companies. Martek Biosciences produces life'sDHA, its own version of the omega-3 fatty docosahexaenoic acid (DHA), which has found its way into 90% of infant formula in the US.

For older children, the supposed cognitive benefits of omega-3 have led to life'sDHA being incorporated into yoghurts, including products from Danone and Asturiana in Spain. But it is also used in a range of pregnancy products, from Oh Mama! and Belly Bar nutrition bars to GlaxoSmithkline (GSK)'s Mother's (and Junior) Horlicks in India.

The importance of polyunsaturated fatty acids (PUFAs) in general in the maternal diet has been demonstrated by published research, says Singhal at the Institute of Child Health. In particular, he reports, it has established a link between PUFAs and reduced incidence of pre-term births.

But as he points out, trials to date on impacts in infant nutrition have been inconclusive. "They're added to formula and present in human milk, but so far at least, they don't appear to have any long-term benefit," he says. Trials have focused on specific functions such as visual acuity. "We're hoping there will turn out to be a benefit," he adds. "But they may well prove to be more important in pregnancy than in the infant."

On the upside​

There is a positive side to this search for PUFA-related benefits, given the nutrition industry's tendency to look for elusive 'magic bullet' ingredients. "The reassuring thing here is that humans have evidently evolved not to be dependent on any single nutrient," says Singhal.

The food and ingredient industry should be equally reassured by the implication that infant nutrition remains, after all, a complex matter.

Meanwhile, as well as the conclusions from the trials component of the EARNEST programme, the industry will be eager to see the results of its parallel research into early nutrition programming, looking at consumer attitudes and economic impact.

Already, though, from an epidemiological standpoint, pre- and postnatal nutrition clearly have massive value as an investment to improve future health prospects in the population. Our understanding of the sheer scale of that value still has some way to go.