Nutrition Publication

NNIW68 - Early Nutrition: Impact on Short- and Long-Term Health

Editor(s): H. Van Goudoever, S. Guandalini, R. Kleinman. 68

The 68th Nestlé Nutrition Institute workshop was dedicated to a research area that is gathering a significant amount of interest in the scientific arena: Early nutrition and its impact on long-term health. Renown Professors van Goudoever, Guandalini and Kleinman had brought together an excellent program summarizing the latest scientific findings on the influence of nutrition in the perinatal period as well as during early and late infancy.

Related Articles

Animal Studies of the Effects of Early Nutrition on Long-Term Health

Author(s): J.E. Harding, A.L. Jaquiery, C.E. Hernandez, M.H. Oliver, J.G.B. Derraik ,F.H. Bloomfield

Small size at birth is associated with increased risk of a variety of common chronic diseases in adulthood. Numerous experimental studies in animals have supported the observations in humans, demonstrating that changes in nutrition in early life can lead to altered long-term health. Importantly, these effects can be independent of size at birth, and can depend on the interaction between nutritional events before and after birth. Both macro- and micro-nutrient intake are important. Furthermore, these effects may vary according to the nature, timing, severity and duration of the nutritional insult. This review provides examples from animal studies of evidence of these long-term effects, and some possible underlying mechanisms whereby nutrition in early life can affect long-term health.

Dietary Lipid Quality and Long-Term Outcome

Author(s): E.M. Novak, B.O. Keller S.M. Innis

How doesthe quality of maternal nutrition affect long-term outcomes in the offspring?Ms. Elizabeth Novak approaches this question from the perspective of fatty acidbiochemistry. She begins by reminding us that fatty acids play the dual role ofenergy source and cellular sensors that can modulate gene expression. Thefundamental importance of fatty acids is seen in the composition of organs:each organ has its unique fatty acid signature, and this blueprint is highlyconserved across such diverse species as humans, elephants, bats and dolphins.Deficiency of dietary omega-3 in pregnant rats results in smaller brains sizein their offspring, in part due to impaired cell migration.A closelook at the protein expression pattern by proteomic analysis reveals afascinating array of molecules affected by omega-3 deficiency, including thosethat affect metabolism and appetite control. Novak concludes her talk with thelatest proteomics findings, showing that maternal lipid supply modulates genetranscription in the offspring via epigenetic mechanisms

How Proteins Improve the Development of Preterm Infants

Author(s): W.E. Corpeleijn, C.H. van den Akker, J.A. Roelants, J.B. van Goudoever

Amino acids and proteins play a pivotal role during growth and development. Besides acting as building blocks during tissue synthesis, amino acids or proteins act specifically by up regulating defense systems or by stimulating key sites in metabolic pathways. Following premature birth, the neonatologist is responsible for delivering the right amount and quality of nutrients to the neonate, while exact requirements are largely unknown. However, nutrition matters, both in quantity as well in quality, especially during the first few weeks and months of life. It is increasingly recognized that proteins and amino acids in the immediate postnatal phase have both short and long term influences on later life.

The Knowns and Unknowns of Human Milk Banking

Author(s): K. Simmer

The provision of donor human milk instead of formula is an important contribution to the nutrition and protection from infections for preterm infants. Systematic reviews suggest a lower risk of necrotising enterocolitis with pasteurised donor human milk (PDHM) as opposed to artificial formula, although evidence supporting PDHM use from randomised control trial is limited. Human milk banks (HMB) must have a risk management system to maintain a safe product especially as many operate in an unregulated environment. To ensure safety, the HMB in Australia has committed to meet the appropriate standards recommended in the Code of Good Manufacturing Practices (Blood and Tissues) and models risk management during processing on Codex HACCP (Hazard Analysis Critical Control Point) requirements. There is scope to continually re-evaluate the screening of donors and quality standards recommended during HMB. This will be most effective if strong networks of HMBs are developed with regional reference laboratories to encourage compliance with safety guidelines. Further research and development is needed to refine technology for treating donor milk such as thermal ultrasound and ultra violet light, aimed at the retention of full bioactivity. HMB networks will facilitate collection of evidence for refining HMB practice which should translate to improved outcomes for preterm and sick infants. Cost effectiveness is most likely when HMBs are associated with large neonatal intensive care units.

Short- and Long-Term Effects of Probiotics Administered Early in Life

Author(s): H. Szajewska

The concept of manipulating the gut microbiota through the administration of probiotics during early life in order to reduce the risk of and prevent or treat diseases, including those that manifest in later life, is appealing. However, a cautious approach is needed, and the long-term consequences of such administration should be carefully evaluated. Concerns related to the early administration of probiotics include timing, i.e., the administration often begins in early infancy, sometimes at birth, when gut microbiota is not fully established, and duration, i.e., the daily administration of such products is prolonged (several weeks or months). In the case of non-breast fed infants, delivery may be in the form of a specific matrix (infant formula) that could be the only source of feeding of an infant over a prolonged period. Finally, the fact that beneficial as well as some detrimental effects are seen years after administration of probiotics during the first months of life raises concern that other long-term effects such as immunosuppression in later life may also occur. Currently, while some promising data exist, there are still more questions than answers. However, rapid progress in this area of research is expected and no doubt will bring about a number of exciting findings.

New Findings from the Feeding Infants and Toddlers Study 2008

Author(s): A.M. Siega-Riz

Limited information exists from large, national samples in the U.S. that can contribute to our understanding of the parental behaviors potentially leading to early childhood obesity. The purpose of this paper is to describe the infant feeding practices in terms of breastfeeding and use of milk substitutes as well as the introduction of complementary foods among infants and toddlers (aged 0-24 months) and to describe food group consumption patterns of these infants and young children (0-48 months) participating in the 2008 Feeding Infants and Toddlers Study (FITS). The FITS 2008 is a cross-sectional survey of a national sample of U.S. children; this analysis includes 3,273 children. Results indicate a longer duration of breastfeeding, based on a higher proportion of 9- to 12-month old infants who were breastfed and a smaller proportion that were fed formula compared to the 2002 survey. However, 17% of infants received cow’s milk before the recommended age of 1 year. Introduction of complementary foods also appears to be delayed until about 4 to 6 months. There was a decline in consumption of infant cereal after 8 months (replaced by non-infant cereal) that may be contributing to iron deficiencies in the 9-11 month age group. Consumption of 100% juice in FITS 2008 (particularly among infants) and the daily consumption of desserts or candy, sweetened beverages (particularly among 12- to 20-month olds), and salty snacks is lower than in the 2002 survey. Overall, 10-20% and 30% of children were not consuming any fruit or vegetable, respectively, in a given day. More preschoolers were drinking 2% milk than whole milk, but about one third were still drinking whole milk. Despite some of these positive changes, improvements in young children’s diet still are needed, in particular related to providing a rich source of iron to infants at 9 to 12 months, increasing the daily consumption of fruits and vegetables, as well as decreasing the intake of dessert, candy, salty snacks, and sweetened beverages that contribute discretionary calories.

Weaning Practices in Other Parts of the World: Case Study India

Author(s): K.N. Agarwal

Infant feeding and weaning practices in India continue to demonstrate that a significant number of infants do not receive colostrum (62.8% as per National Family Health Survey, NFHS-2), though breast feeding is universal and continued for a longer period. In NFHS-3 (2005-06) there is improving trend for breast feeding within first hour of birth (23.4%); exclusive breast feeding up to 5 months (46.3%), however weaning for semisolids is delayed (55.8% only in 6-9 months of age). The infant weaning foods are inadequate in energy-protein and micronutrients. Also, weaning foods and feeding/cooking utensils are loaded with bacterial contamination resulting in frequent episodes of diarrhea. These are the factors responsible for continued early malnutrition which the country has failed to control as observed in the three National Family Health Surveys. Over a span of 7 years i.e., from National Family Health Survey (NFHS)-2 (1998-99) to NFHS-3 (2005-6), there was only marginal reduction in under nutrition. Thus uncontrolled fetal malnutrition, poor initiation of breast feeding, inadequate and delayed weaning, and contamination in food and water demand urgency to develop affordable hygienic weaning foods, education to clean utensils, timely weaning and available potable chlorinated water to prevent and control malnutrition.

Weaning Practices in Other Parts of the World: Case Study Russia

Author(s): A.K. Baturin

Objectives of the survey. To evaluate infant feeding and weaning practices and anthropometric characteristics of children from 2 to 24 months old in RussiaSurvey Method. A comprehensive analysis of data collected by face to face interviews from a random Russia representative sample of 2582 mothers of children. We used a specially designed questionnaire that includes sections on health, especially feeding practices, food intake for the previous day and the measurement of length and weight.Survey conducted within frames of “Start Health Stay Health” Program in Russia, sponsored by Gerber, Nestle NutritionResults: Prevalence of breastfeed infants: since 2 to 4 months – 70%, since 4 to 6 months – 60%, since 6 to 9 months - 46%, since 9 to 12 months- 39%.The most common weaning foods was fruit juice (59,4% of children), followed by fruit puree (18%) and cereals (6,4%). 4,4% of respondents used as a first weaning using cow's milk.It was found that examined children is slightly higher (Z-score of height for age is 0.11) and heavier (Z-score weight for age is 0.63) than the WHO standards.Conclusions. Evaluation of infant/toddlers feeding and weaning practice will help to develop guidelines and educational programs to prevent nutrition- related diseases in Russia.

Micronutrient Deficiencies and Effect of Supplements on Correcting Them

Author(s): S. Zlotkin

Dr. Stanley Zlotkin presents an innovative success story on the treatment of micronutrient deficiencies in children worldwide. His starting point is anemia, the most prevalent form of micronutrient deficiency in children under 5 years of age.Zlotkin goes through the possible solutions to this problem, and demonstrates the need for tailored strategies in developing countries. For example, general and targeted food fortification is only realistic in developed countries, and the use of iron supplements is simply not feasible in children. What other options can we explore? Zlotkin and his collaborators have invented "Sprinkles", a safe, effective, inexpensive and convenient powder sachet containing various micronutrients. Sprinkles can be modified according to the target population in order to address specific deficiencies: Vitamin A in Ghana, Vitamin D in Mongolia, iron in Bangladesh and zinc in Pakistan. He takes us through the data showing the efficacy, compliance, and clinical benefits in several developing countries. The final challenge: to establish a reliable distribution and supply chain so that parents can gain access to these valuable micronutrient sachets.

Food Allergy and Complementary Feeding

Author(s): W.G. Shreffler, M. Radano

Food allergy is thought to be a manifestation of failed oral tolerance induction that is likely to be the result of complex interactions between gut permeability/ maturity, bacterial colonization, and the timing and route of antigen exposure. Complementary feeding recommendation must be informed by multiple health considerations of the infant/ toddler transitioning from breast milk (or infant formula) to family food. The impact of complementary feeding choices on either food allergy or sensitization to food allergens or on atopic eczema appear to be modest and should probably be secondary to other heath considerations. If anything, the current data generally point to an increased, rather than decreased, risk of food allergy or related conditions associated with delayed introduction (beyond 4-6 months) of solid foods, including allergenic foods such as peanut and fish. This tentative conclusion is also more consistent with current paradigms of oral immune tolerance.

Early Feeding: Setting the Stage for Healthy Eating Habits

Author(s): J.A. Mennella, A.K. Ventura

Food habits, an integral part of all cultures, have their beginnings during early life. This chapter reviews the development of the senses of taste and smell, which provide information on the flavor of foods, and discusses how children’s innate predispositions interact with early-life feeding experiences to form dietary preferences and habits. Young children show heightened preferences for foods that taste sweet and salty and rejection of that which tastes bitter. These innate responses are salient during development since they likely evolved to encourage children to ingest that which is beneficial, containing needed calories or minerals, and to reject that which is harmful. Early childhood is also characterized by plasticity, partially evidenced by a sensitive period during early life when infants exhibit heightened acceptance of the flavors experienced in amniotic fluid and breast milk. While learning also occurs with flavors found in formulas, it is likely that this sensitive period formed to facilitate acceptance of and attraction to the flavors of foods eaten by the mother. A basic understanding of the development and functioning of the chemical senses during early childhood may assist in forming evidence-based strategies to improve children’s diets.

Early Feeding Practices and Development of Food Allergies

Author(s): G. Lack, M. Penagos

Despite increasing efforts to prevent food allergies in children, IgE-mediated food allergies continue to rise in westernized countries. Previous preventive strategies such as prolonged exclusive breastfeeding and delayed weaning onto solid foods have more recently been called into question. The present review discusses possible risk factors and theories for the development of food allergy. An alternative hypothesis is proposed, suggesting that early cutaneous exposure to food protein through a disrupted skin barrier leads to allergic sensitization and that early oral exposure of food allergen induces tolerance. Novel interventional strategies to prevent the development of food allergies are also discussed.

Learning to Prefer the Familiar in Obesogenic Environments

Author(s): L.L. Birch, S. Anzman-Frasca

What has become familiar tends to be preferred while the unfamiliar is avoided. Additionally, liking is impacted by associative learning processes where new stimuli become liked via repeated pairings with familiar, already-liked stimuli. In addition to the ability to learn to like new foods and flavors, infants bring genetic taste predispositions to the table, including an unlearned preference for sweet and salty tastes, whereas bitter and sour tastes are rejected. When diets were plant-based, unlearned preferences for sweet and salty tastes promoted intake of foods that were relatively rare in nature but were good sources of essential nutrients; the presence of the preferred basic tastes in food no longer predicts scarce nutrients. Our "obesogenic" dietary landscape is replete with sweet and salty foods that are energy dense, inexpensive, and exquisitely tuned to our genetic taste predispositions. In the current environment, early familiarization and associative learning can result in unhealthy diets and may promote obesity risk, but we suggest applying what we know about how food liking is learned to promote healthier diets. We review classic and current evidence demonstrating how familiarization and associative learning may be used to promote the intake of initially-rejected foods like vegetables within an obesogenic context.

Early Feeding Practices and Their Impact on Development of Celiac Disease

Author(s): A. Fasano, C. Catassi

Celiac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. Gluten is a protein component in wheat and other cereals like rye and barley that are generally introduced in the infant’s diet at weaning. At present, two schools of thought claim that changing early feeding regimens in at-risk infants can either prevent the onset of the disease or merely delete its onset. Recent advances have increased our understanding of the molecular basis of this disorder and provide the rationale to perform prospective dietary interventional studies to establish the proper timing of gluten exposure to minimize the risk of developing CD.

Infant Feeding Practices and Subsequent Development of Adipose Tissue

Author(s): N. Stettler

The main aspects of infant feeding that have been studied in humans in association with the subsequent development of adipose tissue include breastfeeding, rapid infancy weight gain, and weaning practices. While observational studies have consistently shown a protective effect of breastfeeding on the development of obesity, these studies may be confounded by unmeasured or unknown confounding factors, as suggested by one study using a sibling design and one study using a randomized breastfeeding promotion intervention design. Observational studies and findings from a limited number of experimental studies suggest that rapid weight gain during infancy may be associated with an increased risk for obesity in childhood and adulthood. The association of weaning practices with later obesity has not been extensively studied and the preliminary findings are inconsistent. Additional research studies, especially randomized interventions with long-term follow-up, are necessary in order to assess if short nutrition interventions during the critical period of infancy can have long-term benefits on the prevention of obesity.

Early Life Nutrition and Bone Development in Children

Author(s): G. Jones

Fetal and early life may be a critical period for the development and/or programming of metabolic systems, including the skeleton. There is increasing human data from cohort studies on the association between early life nutrition and bone development in children. Breastfed children initially have lower bone mass than bottle fed children but longer term studies suggest that they have higher bone mass (size adjusted) by age 8 especially in children born at term. By the time of peak bone mass, both preterm and term children have higher bone mass indicating a different bone accrual trajectory curve. These children also have lower fracture risk. Diet in utero has also been associated with subsequent bone mass from ages 6 to 16 (but not fracture). Positive associations include milk, phosphorus, magnesium, potassium, protein, folate, calcium and vitamin D while fat intake is negative. Smoking also interferes with bone mineralization possibly due to impaired placental function but this deleterious effect on bone mass appears to diminish over time. All of these associations are statistically significant and independent of important confounders and later environmental exposures suggesting that osteoporosis prevention programs need to start very early in the life cycle.

IGF-I Signaling and Effects on Longevity

Author(s): M. Holzenberger

Insulin and insulin-like signaling regulate survival and lifespan in a variety of animal models, from nematodes and flies to higher vertebrates and mammals. Recently, it was shown that brain IGF-1 receptor and brain IRS2 control mammalian lifespan, and that this occurs through neuroendocrine mechanisms, control of energy metabolism and modified stress resistance. Furthermore, it was demonstrated that IRS molecules are implicated downstream of insulin and IGF receptors in the extension of lifespan. We showed recently that early postnatal diet plays a significant role in the development of the somatotropic axis, and that part of the neuroendocrine plasticity of growth hormone secretion depends on postnatal nutrition. In that model, the prevalence of cardiovascular and metabolic pathologies varied with the development of somatotropic function. Neuroendocrine pathways are also prime targets for pharmacological treatments, and administration of rapamycin to adult mice has indeed recently been reported to prolong lifespan in mice. With respect to human aging, new studies identified several genes of the somatotropic axis as longevity determinants, and a recent study shows that variants of FOXO3A, downstream signaling molecule in the insulin/IGF pathway, are associated with extreme longevity in humans. Finally, several functional mutations of the human IGF-1R have been discovered in centenarians.