Patent Grant
11389403
This application is the National Phase of International Patent Application No. PCT/EP2016/074810 filed Oct. 14, 2016, published on Apr. 20, 2017 as WO 2017/064304 A1, which claims priority to European Patent Application No. 15190039.6, filed Oct. 15, 2015. The contents of these applications are herein incorporated by reference in their entirety.
The invention relates to nutrition for infants, in particular infant formula, intended to be used as a sole source of nutrition.
Human milk is the uncontested gold standard concerning infant nutrition. However, in some cases breastfeeding is inadequate or unsuccessful for medical reasons or because of a choice not to breastfeed. For such situations infant or follow on formulas have been developed. Commercial infant formulas are commonly used today to provide supplemental or sole source of nutrition early in life. These formulas comprise a range of nutrients to meet the nutritional needs of the growing infant, and typically include fat, carbohydrate, protein, vitamins, minerals, and other nutrients helpful for optimal infant growth and development. Commercial infant formulas are designed to mimic, as closely as possible, the composition and function of human milk.
Since long it has been appreciated that breastfed infants have a different weight gain pattern or trajectory compared to formula-fed infants. After the first week of life, in which breastfed infants initially tend to lose more weight than formula-fed infants and take slightly longer to regain their birth weight, the weight gain patterns are similar between breastfed and formula-fed infants for the first 4 months of life. Breastfed infants tend to have slightly higher weight at 3 months age (Andres et al, 2013, J Pediatrics 163: 49-54). After about 4 months of age, the rate of weight gain diverges markedly between breastfed and formula-fed infants. The difference in average weight at 12 months approximates up to 500-650 g (Dewey et al., 1993, Am J Clin Nutr 57: 140-145). Numerous studies performed in various regions from all over the world have reported that breastfed infants have a slower weight gain between 4 and 12 months of life in Western developed countries as well as in non-Western developing countries. Length gain tends to differ less between breastfed and formula-fed infants and as a result breastfed infants are leaner at 12 months of age (Dewey et al., 1993). Thus, in the art it has been indicated that the growth curve of infants fed with commercial infant formula differs from the growth curve of breastfed infants. Typically the infant formula has a growth accelerating effect in the first year of life, in particular from 4 months of age onwards, resulting in a higher weight at 12 months of age (Dewey et al., 1993; Dewey et al, 1992 Pediatrics 89:1035).
In the prior art in the field of infant formula for improving the growth trajectory to be more similar to the growth trajectory of breastfed infants, the focus is on infant formula with lower protein and/or lower caloric density. WO 2008/071667 discloses a nutritional composition for infants at risk of developing obesity later in life comprising a protein source, a lipid source and a carbohydrate source. The protein content is less than 1.8 g/100 kcal and the energy density is less than 650 kcal/litre. In WO 2010/070613 it is disclosed that a lower weight gain in the first week of life was observed when using a formula with a very low caloric content and low protein content based on volume. Koletzko et al, 2009, Am J Clin Nutr 89:1836-1845 disclose that using an isocaloric infant and follow on formula with a protein content of 1.77 and 2.1 g/100 kcal resulted in less weight gain than in the group of infants consuming an infant or follow on formula with a high protein concentration of 2.9 and 4.4 g/100 kcal. At 24 months, the weight-for-length z-score of infants in the lower protein formula group was lower than that of the high protein group and did not differ from that of the breastfed reference group. In WO 2015/078505 a lower weight gain is observed in the 3 to 6 months period when a formula is administered comprising a lower protein content than in the control. WO 2015/091789 focusses on oligosaccharide mixtures comprising N-acetylated oligosaccharide, galacto-oligosaccharide and/or sialylated oligosaccharide promoting a rate of growth which approximates to the rate of growth of a breast-fed infants.
In WO 2013/153071 it is presented that formula are tested comprising sialic acid, cholesterol, sphingomyelin, and a lower caloric content and lower protein content compared to the control formula. No difference was observed in the growth up to 6 month when looking at age adjusted z-scores, when feeding these formulas and compared to breastfed infants. In Timby et al, 2014, Am J Clin Nutr 99:860-868 the 12 month data of a similar study show that both formula fed groups show statistically significant higher growth velocity than the breastfed reference group for weight and length. In WO 2009/051502 infant formula rich in a source of gangliosides are disclosed to increase or maintain a healthy growth. A postnatal increase in body weight was observed in rats receiving a gel enriched in gangliosides.
Human milk lipids have a distinct physical structure composed of large lipid globules with an average mode diameter of about 4 μm existing of a triglyceride core coated by a tri-layer of membranes, the milk fat globule membrane (MFGM). The diameter of lipid droplets in standard infant formula is about 0.3-0.5 μm due to the industrial processing procedures to achieve stable and reproducible end products, and is not surrounded by MFGM but mostly by proteins such as casein. Infant formula with lipid globules with an architecture more similar to the lipid globules in human milk have been described. WO 2015/065193 discloses nutritional compositions comprising specifically designed lipid globules for preterm infants, small for gestational age infants and infants with retarded growth due to physical or mental stress after birth, for promoting catch up growth and/or improved body composition. In WO 2012/173467 the use of specifically designed lipid component with optimal fatty acid profile, an enhanced portion of the palmitic acid residues at the sn-2 position and present as lipid globules with a certain size and/or coating is disclosed for an early in life diet for improving the development of a healthy body composition, in particular prevention of obesity, later in life.
The inventors compared the growth pattern or growth trajectory of 3 groups of healthy term infants during the first 12 months of life with each other and with the WHO Child Growth Standards of breastfed infants. One group was a non-randomised reference group of breastfed infants, one group received an experimental infant formula comprising a lipid component in the form of large lipid globules coated with phospholipids, and one group received a control infant formula without a lipid component in the form of large lipid globules coated with phospholipids, but in the form of standard lipid globules coated with protein. Both formulas were administered up to 17 weeks of life. The control and experimental milk formula were similar in caloric content, as well as in fat, carbohydrate and protein content.
The inventors surprisingly found that when analysing the growth trajectories for the whole study period up to 12 months of age in the per protocol (PP) population with a parametric growth curve (PGC), the group of infants receiving the experimental formula was not statistically different from the breastfed reference group, when looking at weight and body mass index (BMI) at 12 months of age. The group receiving control formula on the other hand showed a statistically significant higher weight and BMI at 12 months, when compared with the breastfed reference group. Furthermore the group receiving control formula showed a statistically significant higher BMI, when compared with the group fed with the experimental formula at 12 months.
In the control group, analysing the intention to treat (ITT) population, the mean weight-for-age z-score, weight-for-length z-score and BMI-for age z-score at 12 months of age were significantly higher compared to the WHO Child Growth Standards of breastfed infants. In the control group, analysing the intention to treat (ITT) population, the mean head circumference-for-age z-score, was significantly higher compared to the WHO Child Growth Standards of breastfed infants. The experimental group on the other hand was more similar to the breastfed reference group for all these z-scores as indicated by the overlapping confidence intervals and for both groups (experimental formula fed group and breastfed reference group) there was no indication for a difference from the WHO Child Growth Standards.
This indicates that feeding an infant formula with a similar caloric content and macro-ingredient content can have a different and beneficial effect on the growth pattern or growth trajectory early in life, rendering it advantageously more similar to the growth pattern or trajectory early in life of breastfed infants. This is due to the difference in which the way the lipid component is configured, namely in a way more resembling human milk lipid globules, by being larger in size and/or coated with phospholipids.
The present invention thus concerns a method for promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is similar to the growth trajectory or body development observed in human milk fed infants, said method comprising administering a nutritional composition selected from an infant formula and a follow on formula to an infant, wherein the nutritional composition comprises 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and wherein the nutritional composition comprises lipid globules having
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids.
In one embodiment, a growth trajectory or body development which is similar to the growth trajectory or body development observed in human milk fed infants, is a growth trajectory or body development which is closer to the optimal growth trajectory or body development of the WHO Child Growth Standards of human milk fed infants. In the context of the present invention, the WHO Child Growth Standards of human milk fed infants refers to the WHO Child Growth Standards published in Acta Paediatrica, April 2006, volume 95, supplement 450.
In the context of the present invention ‘similar’ or ‘closer’ is compared to when a standard infant formula of follow on formula not comprising lipid globules having a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or b) on the surface at least partly a coating of phospholipids is administered, more in particular when compared to standard infant formula of follow on formula comprising lipid globules of about 0.5 μm and that do not have a coating of phospholipids.
As an alternative to the ‘promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is similar to the growth trajectory or body development observed in human milk fed infants’, the present invention also concerns improving the postnatal growth trajectory or body development in an infant towards the growth trajectory or body development observed in human milk fed infants, preferably when compared to the growth trajectory or body development in infants fed infant formula of follow on formula comprising lipid globules of about 0.5 μm and that do not have a coating of phospholipids.
Thus in one embodiment, the present invention concerns a method for improving the postnatal growth trajectory or body development in an infant towards the growth trajectory or body development observed in human milk fed infants, preferably when compared to the growth trajectory or body development in infants fed infant formula of follow on formula comprising lipid globules of about 0.5 μm and that do not have a coating of phospholipids, wherein the nutritional composition comprises 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and wherein the nutritional composition comprises lipid globules having
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids.
Alternatively, the present invention concerns a method for promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is closer to the optimal growth trajectory or body development of the WHO Child Growth Standards of human milk fed infants, said method comprising administering a nutritional composition selected from an infant formula and a follow on formula to an infant, wherein the nutritional composition comprises 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and wherein the nutritional composition comprises lipid globules having
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids.
In some jurisdictions administering a nutritional composition to an infant is considered non-therapeutic. In those instances the invention can be worded as defined above by way of a method comprising administering a nutritional composition. For clarity, the method can also be defined as a non-therapeutic method for promoting a postnatal growth trajectory or body development in an infant as defined above. By definition, the words “non-therapeutic” exclude any therapeutic effect.
In some jurisdictions administering a nutritional composition to an infant is considered therapeutic per se. In this instances the invention can be worded as follows.
In one embodiment the invention concerns the use of lipid globules in the manufacture of a nutritional composition selected from an infant formula and a follow on formula for use in promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is similar to the growth trajectory or body development observed in human milk fed infants, wherein the nutrition composition comprises 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and the lipid globules have
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids.
In one embodiment the invention concerns the use of lipid globules in the manufacture of a nutritional composition selected from an infant formula and a follow on formula for use in improving the postnatal growth trajectory or body development in an infant towards the growth trajectory or body development observed in human milk fed infants, preferably when compared to the growth trajectory or body development in infants fed infant formula of follow on formula comprising lipid globules of about 0.5 μm and that do not have a coating of phospholipids, wherein the nutrition composition comprises 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and the lipid globules have
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids.
In one embodiment the invention concerns the use of lipid globules in the manufacture of a nutritional composition selected from an infant formula and a follow on formula for use in promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is closer to the optimal growth trajectory or body development of the WHO Child Growth Standards of human milk fed infants, wherein the nutrition composition comprises 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and the lipid globules have
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids.
The invention can also be worded as a nutritional composition selected from an infant formula and a follow on formula comprising 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and comprising lipid globules having
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids for use in promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is similar to the growth trajectory or body development observed in human milk fed infants.
The invention can also be worded as a nutritional composition selected from an infant formula and a follow on formula comprising 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and comprising lipid globules having
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids
for use in improving the postnatal growth trajectory or body development in an infant towards the growth trajectory or body development observed in human milk fed infants, preferably when compared to the growth trajectory or body development in infants fed infant formula of follow on formula comprising lipid globules of about 0.5 μm and that do not have a coating of phospholipids.
The invention can also be worded as a nutritional composition selected from an infant formula and a follow on formula comprising 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and comprising lipid globules having
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids
for use in promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is closer to the optimal growth trajectory or body development of the WHO Child Growth Standards of human milk fed infants.
In a preferred embodiment of the method, use or composition for use according to the invention, the growth trajectory or body development is the growth trajectory or body development of the first 12 months of life of the infant.
In a preferred embodiment of the method, use or composition for use according to the invention, at 12 months the infant has a weight and/or BMI and/or weight for length that is approximate to the weight and/or BMI and/or weight for length at 12 months of human milk fed infants. In a preferred embodiment of the method, use or composition for use according to the invention, at 12 months the infant has a weight and/or BMI and/or weight for length that is approximate to the weight and/or BMI and/or weight for length at 12 months according to the WHO Child Growth Standards of human milk fed infants. In the context of the present invention, approximate means that it is statistically not different.
In another embodiment of the method, use or composition for use according to the invention, at 12 months the infant has a head circumference that is approximate to the head circumference at 12 months of human milk fed infants. In a preferred embodiment of the method, use or composition for use according to the invention, at 12 months the infant has a head circumference that is approximate to the head circumference at 12 months according to the WHO Child Growth Standards of human milk fed infants. In the context of the present invention, approximate means that it is statistically not different.
In another embodiment of the method, use or composition for use according to the invention, at 12 months the infant has a skinfold thickness, preferably subscapular skinfold thickness or triceps skinfold thickness or both, that is approximate to the skinfold thickness at 12 months of human milk fed infants. In a preferred embodiment of the method, use or composition for use according to the invention, at 12 months the infant has a subscapular skinfold thickness or triceps skinfold thickness or both, that is approximate to the subscapular skinfold thickness or triceps skinfold thickness at 12 months according to the WHO Child Growth Standards of human milk fed infants. In the context of the present invention, approximate means that it is statistically not different.
In one embodiment, the present invention relates to a method for i) promoting a balanced growth trajectory or body development in an infant and/or ii) preventing or reducing the risk of an unbalanced growth trajectory or body development in an infant, said method comprising administering a nutritional composition selected from an infant formula and a follow on formula to an infant, wherein the nutritional composition comprises 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and wherein the nutritional composition comprises lipid globules having
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids.
The invention can also be worded as the use of lipid globules in the manufacture of a nutritional composition selected from an infant formula and a follow on formula for use in i) promoting a balanced growth trajectory or body development in an infant and/or ii) preventing or reducing the risk of an unbalanced growth trajectory or body development in an infant, wherein the nutrition composition comprises 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and the lipid globules have
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids.
The invention can also be worded as a nutritional composition selected from an infant formula and a follow on formula comprising 3 to 7 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal and comprising lipid globules having
a) a mode diameter, based on volume of at least 1.0 μm and/or having a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and/or
b) on the surface at least partly a coating of phospholipids for use in i) promoting a balanced growth trajectory or body development in an infant and/or
ii) preventing or reducing the risk of an unbalanced growth trajectory or body development in an infant.
Preferably a balanced growth trajectory or body development compares or is similar to a growth trajectory or body development observed in human milk fed infants. In one embodiment a balanced growth trajectory or body development is closer to the optimal growth trajectory or body development of the WHO Child Growth Standards of human milk fed infants.
In the context of the present invention, the nutritional composition is not human milk. Also in the context of the present invention, the nutritional composition is not cow's milk, in particular cow's milk that is not homogenised.
Growth
The present invention concerns promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is similar to the growth trajectory or body development observed in human milk fed infants. Synonyms for growth trajectory are growth pattern and growth for age. In the context of the present invention, growth trajectory includes weight pattern, i.e. weight for age, weight-for-length pattern, i.e. weight-for-length-for age and body mass index (BMI) pattern, i.e. BMI for age. In one embodiment, growth trajectory also includes head circumference for age. In one embodiment, growth trajectory also includes subscapular skinfold-for-age or triceps skinfold-for-age or both.
The World Health Organization (WHO) released a new international growth standard statistical distribution in 2006, which describes the growth of children aged 0 to 59 months living in environments believed to support what WHO researchers view as optimal growth of children in six countries throughout the world, including the U.S. The distribution shows how infants and young children grow under these conditions, rather than how they grow in environments that may not support optimal growth. The WHO standards establish growth of the breastfed infant as the norm for growth. The WHO charts reflect growth patterns among children who were predominantly breastfed for at least 4 months and were still breastfeeding at 12 months. The WHO standards provide a better description of physiological growth in infancy. The WHO growth charts are standards in the sense that they identify how children should grow when provided optimal conditions. The WHO standards are based on a high-quality study designed explicitly for creating growth charts. The WHO standards were constructed using longitudinal length and weight data measured at frequent intervals. Also z scores are given. The z score or standard score is the number of standard deviations that an observation or datum is above the mean (for a positive z score) or below the mean (for a negative z score).
Lipid Globule Size
According to the present invention, the nutritional composition comprises lipid globules. When in liquid form these lipid globules are emulsified in the aqueous phase. Alternatively the lipid globules are present in a powder and the powder is suitable for reconstitution with water or another food grade aqueous phase, preferably to provide a ready to drink formula. The lipid globules comprise a core and a surface. The core preferably comprises vegetable fat and preferably comprises at least 90 wt. % triglycerides and more preferably essentially consists of triglycerides. Not all vegetable lipids that are present in the composition need necessarily be comprised in the core of lipid globules, but preferably a major part is, preferably more than 50% wt. %, more preferably more than 70 wt. %, even more preferably more than 85 wt. %, even more preferably more than 95 wt. %, most preferably more than 98 wt. % of the vegetable lipids that are present in the composition are comprised in the core of lipid globules. In one embodiment the core of the lipid globules comprises at least 40 wt. % triglycerides of vegetable origin, more preferably at least 50 wt. %, even more preferably at least 70 wt. % triglycerides of vegetable origin, more preferably the core of the lipid globules comprises at least 85 wt. %, more preferably at least 95 wt. % triglycerides of vegetable origin. The lipid globules in the nutritional composition in the method or use of the present invention have a volume-weighted mode diameter above 1.0 μm, preferably above 3.0 μm, more preferably 4.0 μm or above, preferably between 1.0 and 10 μm, more preferably between 2.0 and 8.0 μm, even more preferably between 3.0 and 8.0 μm, most preferably between 4.0 μm and 8.0 μm. Preferably in addition the size distribution is in such a way that at least 45 volume %, preferably at least 55 volume %, even more preferably at least 65 volume %, even more preferably at least 75 volume % has a diameter between 2 and 12 μm. More preferably at least 45 volume %, preferably at least 55 volume %, even more preferably at least 65 volume %, even more preferably at least 75 volume % has a diameter between 2 and 10 μm. Even more preferably at least 45 volume %, preferably at least 55 volume %, even more preferably at least 65 volume %, even more preferably at least 75 volume % has a diameter between 4 and 10 μm. Preferably less than 5 volume % has a diameter above 12 um.
Standard infant formulae or follow on formulae have lipid globules with mode diameter below 0.5 μm. It was found that large lipid globules promote a growth trajectory or body development that is more similar to that of human milk fed infants. The percentage of lipid globules is based on volume of total lipid. The mode diameter relates to the diameter which is the most present based on volume of total lipid, or the peak value in a graphic representation, having on the X-as the diameter and on the Y-as the volume (%).
The volume of the lipid globule and its size distribution can suitably be determined using a particle size analyzer such as a Mastersizer (Malvern Instruments, Malvern, UK), for example by the method described in Michalski et al, 2001, Lait 81: 787-796.
Coating with Phospholipids
According to the present invention, the nutritional composition preferably comprises polar lipids. Polar lipids are amphipathic of nature and include glycerophospholipids, glycosphingolipids, sphingomyelin and/or cholesterol. More preferably the nutritional composition comprises phospholipids (the sum of glycerophospholipids and sphingomyelin). Polar lipids in the present invention relate to the sum of glycerophospholipids, glycosphingolipids, sphingomyelin and cholesterol. Polar lipids, more preferably phospholipids, are preferably present as a coating on the surface of the lipid globule. By ‘coating’ is meant that the outer surface layer of the lipid globule comprises polar lipids, whereas these polar lipids are virtually absent in the core of the lipid globule. The presence of polar lipids, in particular, phospholipids as a coating or outer layer of the lipid globule in the diet administered was found to advantageously promote a growth trajectory or body development that is more similar to that of human milk fed infants. Thus in one embodiment the coating preferably comprises phospholipids and/or polar lipids. Not all phospholipids and/or polar lipids that are present in the composition need necessarily be comprised in the coating, but preferably a major part is. Preferably more than 30 wt. %, more preferably more than 50 wt. %, more preferably more than 70 wt. %, even more preferably more than 85 wt. %, most preferably more than 95 wt. % of the phospholipids and/or polar lipids that are present in the composition are comprised in the coating of lipid globules. In a preferred embodiment the nutritional composition in the method or use according to the present invention comprises phospholipids, preferably the nutritional composition comprises at least 0.5 wt. % phospholipids based on total lipid. Yet further preferably the phospholipids comprise at least 15 wt. % sphingomyelin based on total phospholipids.
In one embodiment, in the nutritional composition in the method or the use according to the invention, the lipid globules have a volume mode diameter of 1.0 μm or above, and are at least partly coated on the surface with phospholipids. Preferably the amount of phospholipids present in the nutritional composition ranges from 0.5 to 20 wt. % phospholipids based on total lipid. A combination of large lipid globule size and coating further promotes a growth trajectory or body development that is more similar to that of human milk fed infants, when compared to small and not phospholipid coated lipid globules.
According to the present invention, the nutritional composition preferably comprises glycerophospholipids. Glycerophospholipids are a class of lipids formed from fatty acids esterified at the hydroxyl groups on carbon-1 and carbon-2 of the backbone glycerol moiety and a negatively-charged phosphate group attached to carbon-3 of the glycerol via an ester bond, and optionally a choline group (in case of phosphatidylcholine, PC), a serine group (in case of phosphatidylserine, PS), an ethanolamine group (in case of phosphatidylethanolamine, PE), an inositol group (in case of phosphatidylinositol, PI) or a glycerol group (in case of phosphatidylglycerol, PG) attached to the phosphate group. Lysophospholipids are a class of phospholipids with one fatty acyl chain. Preferably the present composition contains PC, PS, PI and/or PE, more preferably at least PC.
Preferably the nutritional composition comprises sphingomyelin. Sphingomyelins have a phosphorylcholine or phosphorylethanolamine molecule esterified to the 1-hydroxy group of a ceramide. They are classified as phospholipid as well as sphingolipid, but are not classified as a glycerophospholipid nor as a glycosphingolipid. Preferably the nutritional composition comprises 0.05 to 10 wt. % sphingomyelin based on total lipid, more preferably 0.1 to 5 wt. %, even more preferably 0.2 to 2 wt. %.
According to the present invention, the nutritional composition preferably comprises glycosphingolipids. The term glycosphingolipids as in the present invention particularly refers to glycolipids with an amino alcohol sphingosine. The sphingosine backbone is O-linked to a charged headgroup such as ethanolamine, serine or choline backbone. The backbone is also amide linked to a fatty acyl group. Glycosphingolipids are ceramides with one or more sugar residues joined in a β-glycosidic linkage at the 1-hydroxyl position. Preferably the nutritional composition contains gangliosides, more preferably at least one ganglioside selected from the group consisting of GM3 and GD3.
Sphingolipids are in the present invention defined as the sum of sphingomyelin and glycosphingolipids. Phospholipids are in the present invention defined as the sum of sphingomyelin and glycerophospholipids. Preferably the phospholipids are derived from milk lipids. Preferably the weight ratio of phospholipids:glycosphingolipids is from 2:1 to 10:1, more preferably 2:1 to 5:1.
According to the present invention, the nutritional composition preferably comprises phospholipids. Preferably the nutritional composition comprises 0.5 to 20 wt. % phospholipids based on total lipid, more preferably 0.5 to 10 wt. %, more preferably 1 to 10 wt. %, even more preferably 2 to 10 wt. % even more preferably 3 to 8 wt. % phospholipids based on total lipid. Preferably the nutritional composition comprises 0.1 to 10 wt. % glycosphingolipids based on total lipid, more preferably 0.5 to 5 wt. %, even more preferably 2 to 4 wt. %. Preferably the nutritional composition comprises 0.5 to 10 wt. % (glycosphingolipids plus phospholipids) based on total lipid, more preferably 1.0 to 10 wt. % (glycosphingolipids plus phospholipids) based on total lipid. In one embodiment, the nutritional composition for the method or use according to the invention comprises phospholipids, wherein the phospholipids comprise glycolipids, and/or are derived from or form part of the milk fat globule membrane (MFGM), preferably cow's milk MFGM.
According to the present invention, the nutritional composition preferably comprises cholesterol. The nutritional composition preferably comprises at least 0.005 wt. % cholesterol based on total lipid, more preferably at least 0.01 wt. %, more preferably at least 0.02 wt. %, more preferably at least 0.05 wt. %, even more preferably at least 0.1 wt. %. Preferably the amount of cholesterol does not exceed 10 wt. % based on total lipid, more preferably does not exceed 5 wt. %, even more preferably does not exceed 1 wt. % of total lipid.
According to the present invention, the nutritional composition preferably comprises 0.6 to 25 wt. % polar lipids based on total lipid, wherein the polar lipids are the sum of phospholipids, glycosphingolipids, and cholesterol, more preferably 0.6 to 12 wt. %, more preferably 1 to 10 wt. %, even more preferably 2 to 10 wt. %, even more preferably 3.0 to 10 wt. % polar lipids based on total lipid, wherein the polar lipids are the sum of phospholipids, glycosphingolipids, and cholesterol.
Preferred sources for providing the phospholipids, glycosphingolipids and/or cholesterol are egg lipids, milk fat, buttermilk fat and butter serum fat, such as beta serum fat. A preferred source for phospholipids, particularly PC, is soy lecithin and/or sunflower lecithin. According to the present invention, the nutritional composition preferably comprises phospholipids derived from mammalian milk. Preferably the nutritional composition comprises phospholipids and glycosphingolipids derived from milk. Preferably also cholesterol is obtained from milk. Preferably the polar lipids, in particular phospholipids, are derived from milk. Polar lipids, in particular phospholipids, derived from milk include the polar lipids, in particular phospholipids, isolated from milk lipid, cream lipid, cream serum lipid, butter serum lipid, beta serum lipid, whey lipid, cheese lipid and/or buttermilk lipid. The buttermilk lipid is typically obtained during the manufacture of buttermilk. The butter serum lipid or beta serum lipid is typically obtained during the manufacture of anhydrous milk fat from butter. Preferably the phospholipids, glycosphingolipids and/or cholesterol are obtained from milk cream. The nutritional composition preferably comprises phospholipids, glycosphingolipids and/or cholesterol from milk of cows, mares, sheep, goats, buffalos, horses and camels. It is most preferred to use a lipid extract isolated from cow's milk. The use of polar lipids from milk fat advantageously comprises the polar lipids from milk fat globule membranes, which are more reminiscent to the situation in human milk. Polar lipids, in particular phospholipids, derived from fat milk advantageously promote a growth trajectory more effectively than polar lipids from other sources. The polar lipids, in particular phospholipids, are located on the surface of the lipid globule, i.e. as a coating or outer layer. It was found that when the polar lipids or phospholipids are present in the coating of the lipid globule they are more effective than when they are dry blended into the powdered product, i.e. present as ingredient as such. A suitable way to determine whether the polar lipids are located on the surface of the lipid globules is laser scanning microscopy. The concomitant use of polar lipids in particular phospholipids, derived from domestic animals milk and triglycerides derived from vegetable lipids therefore enables to manufacture coated lipid globules with a coating more similar to human milk, while at the same time providing an optimal fatty acid profile. Suitable commercially available sources for milk polar lipids are BAEF, SM2, SM3 and SM4 powder of Corman, Salibra of Glanbia, and LacProdan MFGM-10 or PL20 from Arla. Preferably the source of milk polar lipids comprises at least 4 wt. % phospholipids based on total lipid, more preferably 7 to 75 wt. %, most preferably 20 to 70 wt. % phospholipids based on total lipid. Preferably the weight ratio phospholipids to protein is above 0.10, more preferably above 0.20, even more preferably above 0.3. Preferably at least 25 wt. %, more preferably at least 40 wt. %, most preferably at least 75 wt. % of the polar lipids, in particular phospholipids, is derived from milk polar lipids.
Methods for obtaining lipid globules with an increased size and/or coating with phospholipids are disclosed in WO 2010/0027258, WO 2010/0027259 and WO 2013/135738.
Preferably in the nutritional composition in the method or the use according to the invention, the lipid globules are both increased in size, compared to the size in standard infant formula, as well as at least partly coated with phospholipids. Thus in one embodiment in the nutritional composition in the method or the use according to the invention, the lipid globules have
a) a mode diameter, based on volume of at least 1.0 μm and/or a diameter of 2 to 12 μm in an amount of at least 45 volume % based on total lipid, and
b) on the surface at least partly a layer of phospholipids.
All preferred embodiments described for lipid globule size and for coating with phospholipids described above apply to the combination of both features as well.
Infant Formula and Follow on Formula
The nutritional composition to be administered in the method or use according to the present invention is selected from an infant formula and a follow on formula. This means that the present nutrition composition is not human milk. Alternatively the term “formula” means that it concerns a composition that is artificially made or in other words that it is synthetic. Hence in one embodiment the nutritional composition is selected from an artificial infant formula and an artificial follow on formula or a synthetic infant formula and a synthetic follow on formula. In the present context, infant formula refers to nutritional compositions, artificially made, intended for infants of 0 to about 4 to 6 months of age and are intended as a substitute for human milk. Typically infant formulae are suitable to be used as sole source of nutrition. Such formulae are also known as starter formula. Formula for infants starting with at 4 to 6 months of life to 12 months of life are intended to be supplementary feedings to infants that start weaning on other foods. Such formulae are also known as follow on formulae. Infant and follow on formulae are subject to strict regulations, for example for the EU Commission Directive 2006/141/EC.
The nutritional composition comprises 3 to 7 g lipid/100 kcal, preferably 4 to 6 g lipid/100 kcal, more preferably 4.5 to 5.5 g lipid/100 kcal, 1.25 to 5 g protein/100 kcal, preferably 1.35 to 4 g protein/100 kcal, more preferably 1.5 to 3 g protein/100 kcal, more preferably 1.25 to 2.5 g protein/100 kcal, more preferably 1.25 to 2.25 g/100 kcal, even more preferably 1.25 to 2.1 g protein/100 kcal and 6 to 18 g digestible carbohydrate/100 kcal, preferably 8 to 16 g digestible carbohydrate/100 kcal, more preferably 10 to 15 g digestible carbohydrate/100 kcal.
Lipid
Herein LA refers to linoleic acid and/or acyl chain (18:2 n6); ALA refers to α-linolenic acid and/or acyl chain (18:3 n3); PUFA refers to polyunsaturated fatty acids and/or acyl chains; MUFA refers to monounsaturated fatty acids and/or acyl chains; LC-PUFA refers to long chain polyunsaturated fatty acids and/or acyl chains comprising at least 20 carbon atoms in the fatty acyl chain and with 2 or more unsaturated bonds; DHA refers to docosahexaenoic acid and/or acyl chain (22:6, n3); EPA refers to eicosapentaenoic acid and/or acyl chain (20:5 n3); ARA refers to arachidonic acid and/or acyl chain (20:4 n6); DPA refers to docosapentaenoic acid and/or acyl chain (22:5 n3). PA relates to palmitic acid and/or acyl chains (C16:0). Medium chain fatty acids (MCFAs) refer to fatty acids and/or acyl chains with a chain length of 6, 8 or 10 carbon atoms.
The lipid in the nutritional composition to be administered in the method or use according to the present invention preferably comprises vegetable lipids. The lipid that is present in the nutritional composition in the method or use according to the invention preferably comprises PUFAs, more preferably LC-PUFAs, as LC-PUFAs further improve the growth patterns and body development. The nutritional composition preferably comprises 5 to 35 wt. % PUFA, more preferably 10 to 30 wt. % PUFA, most preferably 15 to-20 wt. % PUFA, based on total lipid. In one embodiment the lipid in the nutritional composition for the method or use according to the invention comprises at least 10 wt. % polyunsaturated fatty acid based on total fatty acids. It is also preferred that the nutritional composition comprises MUFAs, preferably 10 to 80 wt. % MUFA, more preferably 20 to 70 wt. % MUFA, most preferably 35 to 55 wt. % MUFA, based on total lipid.
LA preferably is present in a sufficient amount in order to promote a healthy growth and development, yet in an amount as low as possible to prevent occurrence of unbalance in growth or body development. The nutritional composition therefore preferably comprises less than 20 wt. % LA based on total lipid, preferably 5 to 16 wt. %, more preferably 10 to 14.5 wt. %. Preferably, the nutritional composition comprises at least 5 wt. % LA based on total lipid. Per 100 kcal, the nutritional composition preferably comprises 350-1400 mg LA. Preferably, ALA is present in a sufficient amount to promote a healthy growth and development of the infant. The nutritional composition therefore preferably comprises at least 1.0 wt. % ALA based on total lipid. Preferably the nutritional composition comprises at least 1.5 wt. % ALA based on total lipid, more preferably at least 2.0 wt. %. Preferably the nutritional composition comprises less than 12.5 wt. % ALA, more preferably less than 10.0 wt. %, most preferably less than 5.0 wt. %. Preferably the nutritional composition comprises a weight ratio of LA/ALA from 2 to 20, more preferably from 3 to 16, more preferably from 4 to 14, more preferably from 5 to 12.
Preferably the nutritional composition comprises less than 10 wt. % short chain fatty acids based on total fatty acids, preferably less than 8 wt. %, preferably less than 6 wt. %, preferably less than 5 wt. %. Preferably the nutritional composition comprises at least 0.5 wt. % short chain fatty acids based on total fatty acids, preferably at least 0.6 wt. %, less than 8 wt. %, preferably at least 0.9 wt. %, more preferably at least 1.2 wt. %, more preferably at least 2.0 wt. %. Short chain fatty acids are fatty acids with an acyl chain of 2 to 6 carbon atoms. Preferably the nutritional composition comprises less than 10 wt. % butyric acid (acyl chain of 4 carbon atoms) based on total fatty acids, preferably less than 8 wt. %, preferably less than 6 wt. %, preferably less than 5 wt. %, preferably less than 4 wt. %. Preferably the nutritional composition comprises at least 0.5 wt. % butyric acid based on total fatty acids, preferably at least 0.6 wt. %, preferably at least 0.9 wt. %, more preferably at least 1.2 wt. %. The nutritional composition preferably comprises at least 3 wt. % MCFA based on total fatty acids, more preferably at least 10 wt. %, even more preferably 15 wt. %. The present composition advantageously comprises less than 50 wt. % MCFA based on total fatty acids, more preferably less than 30 wt. %, even more preferably less than 20 wt. %.
According to the present invention, the nutritional composition preferably comprises LC-PUFA, more preferably n-3 LC-PUFA, since n-3 LC-PUFA promote an advantageous growth trajectory. More preferably, the nutritional composition comprises EPA, DPA and/or DHA, even more preferably DHA. Since a low concentration of DHA, DPA and/or EPA is already effective and normal growth and development are important, the content of n-3 LC-PUFA in the nutritional composition, more preferably DHA, preferably does not exceed 15 wt. % of the total fatty acid content, preferably does not exceed 10 wt. %, even more preferably does not exceed 5 wt. %. Preferably the nutritional composition comprises at least 0.15 wt. %, preferably at least 0.35 wt. %, more preferably at least 0.75 wt. %, n-3 LC-PUFA, more preferably DHA, of the total fatty acid content. In one embodiment, the present composition comprises at least 0.15 wt. % n-3 LC-PUFA based on total fatty acids selected from the group consisting of DHA, EPA, and DPA, more preferably DHA.
As the group of n-6 fatty acids, especially arachidonic acid (ARA) and LA as its precursor, counteracts the group of n-3 fatty acids, especially DHA and EPA and ALA as their precursor, the nutritional composition comprises relatively low amounts of ARA. The n-6 LC-PUFA, more preferably ARA, content preferably does not exceed 5 wt. %, more preferably does not exceed 2.0 wt. %, more preferably does not exceed 0.75 wt. %, even more preferably does not exceed 0.5 wt. %, based on total fatty acids. As the presence of ARA is not necessary for promoting a growth trajectory of body development similar to that of human milk fed infants, ARA may also be absent.
Palmitic Acid at Sn-2 Position of Triglyceride
The lipid in the nutritional composition to be administered in the method or use according to the present invention comprises triglycerides. Triglycerides comprise a glyceride molecule to which, via ester bonds, three fatty acid residues are attached, which may be the same or different, and which are generally chosen from saturated and unsaturated fatty acids containing 6 to 26 carbon atoms, including but not limited to LA, ALA, oleic acid (C18:1), PA and/or stearic acid (C18:0). Such fatty acid triglycerides may differ in the fatty acid residues that are present and/or in the respective position(s) of the fatty acid residues, e.g. in the sn-1, -2 and/or -3 position. Preferably the triglycerides used in the nutritional composition are chosen such that the amount of PA residues that are present in the triglycerides are 10 wt. % or more based on total fatty acid present in the triglycerides, preferably more than 15 wt. %. Thus in one embodiment in the nutritional composition in the method or use according to the invention, the lipid comprises triglycerides that comprise at least 10 wt. % palmitic acid based on total fatty acids, and wherein at least 15% of the palmitic acid is present at the sn-2 position of the triglycerides. Preferably the amount of PA residues that are present in the triglycerides are below 30 wt. %, more preferably between 16 and 24%. Preferably the triglycerides used in the nutritional composition are chosen such that of the total PA residues present in the triglyceride at least 15%, preferably at least 20%, more preferably at least 30%, even more preferably at least 35%, and most preferably at least 40% are in the sn-2 or beta position of the triglyceride.
Suitable triglycerides for the nutritional composition in the method or use according to the invention are commercially available, e.g. from Loders Croklaan under the name Betapol™ and/or can be prepared in a manner known per se, for instance as described in EP 0 698 078 and/or EP 0 758 846. Another suitable source is InFat™ of Enzymotec. In case these lipids are obtained by trans- or interesterification of vegetable triglycerides, these sources are in the context of the present invention regarded as vegetable lipids. Preferably the amount of the triglyceride with increased amount of palmitic acid residues on the sn-2 position of a trygliceride molecule that is comprised in the lipid fraction of the composition that is to be administered according to the present method or use, is between 10 and 100 wt. %, preferably between 20 and 100 wt. %, more preferably between 20 and 80 wt. %, even more preferably between 50 and 80 wt. %.
A preferred source for triglycerides having palmitic acid at the sn-2 or beta position of the triglyceride is non human animal fat, more preferably non human mammalian milk fat, even more preferably cow's milk fat. Preferably non human mammalian milk fat, in particular cow's milk fat, is preferably used in the form of anhydrous milk fat or butter oil. Preferably the source of the milk fat is in a homogenous fat phase, such as butter oil or anhydrous milk fat, and not in the form of oil in water emulsion such as cream, since the lipid globules of the present nutritional composition can be more easily prepared when in a homogenous fat phase.
Preferably the amount of milk fat is between 10 and 100 wt. % based on total lipid, preferably between 10 and 80 wt. % based on total lipid, more preferably between 10 and 70 wt. %, more preferably between 20 and 80 wt. %, more preferably between 15 to 60 wt. %, more preferably between 20 and 60 wt. %, even more preferably between 25 and 50 wt. % based on total lipid.
Improved promotion of growth trajectory and/or body development similar to that of human milk fed infants was observed when such lipid component with increased amounts of palmitic acid located at the sn-2 position of triglyceride molecules was applied.
Protein
The nutritional composition comprises proteins, preferably in the amounts specified above. The source of the protein should be selected in such a way that the minimum requirements for essential amino acid content are met and satisfactory growth is ensured. Hence protein sources based on cows' milk proteins such as whey, casein and mixtures thereof and proteins based on soy, potato or pea are preferred. In case whey proteins are used, the protein source is preferably based on acid whey or sweet whey, whey protein isolate or mixtures thereof and may include α-lactalbumin and β-lactoglobulin. More preferably, the protein source is based on acid whey or sweet whey from which caseino-glyco-macropeptide (CGMP) has been removed. Preferably the composition comprises at least 3 wt. % casein based on dry weight. Preferably the casein is intact and/or non-hydrolyzed. For the present invention protein includes peptides and free amino acids.
Digestible Carbohydrates
The nutritional composition comprises digestible carbohydrate, preferably in the amounts specified above. Preferred digestible carbohydrate sources are lactose, glucose, sucrose, fructose, galactose, maltose, starch and maltodextrin. Lactose is the main digestible carbohydrate present in human milk. Lactose advantageously has a low glycemic index. The nutritional composition preferably comprises lactose. The nutritional composition preferably comprises digestible carbohydrate, wherein at least 35 wt. %, more preferably at least 50 wt. %, more preferably at least 75 wt. %, even more preferably at least 90 wt. %, most preferably at least 95 wt. % of the digestible carbohydrate is lactose. Based on dry weight the present composition preferably comprises at least 25 wt. % lactose, preferably at least 40 wt. %.
Non Digestible Carbohydrates
In one embodiment the nutritional composition comprises non-digestible oligosaccharides. Preferably the nutritional composition comprises non-digestible oligosaccharides with a degree of polymerization (DP) between 2 and 250, more preferably 3 and 60.
Preferably the present composition comprises fructo-oligosaccharides, inulin and/or galacto-oligosaccharides, more preferably galacto-oligosaccharides, most preferably transgalacto-oligosaccharides. In a preferred embodiment the composition comprises a mixture of transgalacto-oligosaccharides and fructo-oligosaccharides or inulin. Suitable non-digestible oligosaccharides are for example Vivinal GOS (FrieslandCampina DOMO), Raftilin HP or Raftilose (Orafti).
Preferably, the nutritional composition comprises of 80 mg to 2 g non-digestible oligosaccharides per 100 ml, more preferably 150 mg to 1.50 g, even more preferably 300 mg to 1 g per 100 ml. Based on dry weight, the nutritional composition preferably comprises 0.25 wt. % to 20 wt. %, more preferably 0.5 wt. % to 10 wt. %, even more preferably 1.5 wt. % to 7.5 wt. %.
Application
In the method or use according to the present invention, a nutritional composition is administered to an infant or is used in an infant. In the context of the present invention an infant has an age up to 12 months. Preferably the nutritional composition is administered to or is used in a term infant. A term infant means an infant born art a gestational age of 37 to 42 weeks. Preferably the nutritional composition is administered to or is used in a healthy infant. Preferably, the nutritional composition is administered to a male infant. Although the effect of the nutritional composition of the invention on postnatal growth trajectories and body development was observed both in female and male infants, the effect was the largest in male infants. Preferably the nutritional composition is used at least during the first 2 months of life, preferably at least during the first 3 months of life of the infant, more preferably at least during the first 4 months of life of the infant. Preferably the nutritional composition is administered to an infant with an age below 6 months, more preferably below 4 months of age.
According to the present invention, a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is similar to the growth trajectory or body development observed in human milk fed infants is promoted. Alternatively according to the present invention, a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is closer to the optimal growth trajectory or body development of the WHO Child Growth Standards of human milk fed infants is promoted.
As an alternative to the ‘promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is similar to the growth trajectory or body development observed in human milk fed infants’, the present invention also concerns improving the postnatal growth trajectory or body development towards the growth trajectory or body development observed in human milk fed infants, preferably when compared to the growth trajectory or body development in infants fed infant formula of follow on formula comprising lipid globules of about 0.5 μm and that do not have a coating of phospholipids.
Preferably the growth trajectory or body development is selected from the group consisting of the trajectory or development for body weight, weight for length and/or body mass index (BMI). In a preferred embodiment, the growth trajectory or body development is the growth trajectory or body development of the first 12 months of life of the infant. Preferably at 12 months the infant has a weight and/or BMI and/or weight for length that is approximate to the weight and/or BMI and/or weight for length at 12 months of human milk fed infants. Preferably at 12 months the infant has a weight and/or BMI and/or weight for length that is approximate to the weight and/or BMI and/or weight for length at 12 months according to the WHO Child Growth Standards of human milk fed infants.
Preferably the growth trajectory or body development is that for head circumference. In a preferred embodiment, the growth trajectory or body development is the growth trajectory or body development of the first 12 months of life of the infant. Preferably at 12 months the infant has a head circumference that is approximate to the head circumference at 12 months of human milk fed infants. Preferably at 12 months the infant has a head circumference that is approximate to the head circumference at 12 months according to the WHO Child Growth Standards of human milk fed infants.
Preferably the growth trajectory or body development is that for skinfold thickness, preferably that for subscapular skinfold thickness and/or triceps skinfold thickness. In a preferred embodiment, the growth trajectory or body development is the growth trajectory or body development of the first 12 months of life of the infant. Preferably at 12 months the infant has a skinfold thickness, preferably subscapular skinfold thickness and/or triceps skinfold thickness, that is approximate to the skinfold thickness at 12 months of human milk fed infants. Preferably at 12 months the infant has a subscapular skinfold thickness and/or triceps skinfold thickness that is approximate to the subscapular skinfold thickness and/or triceps skinfold thickness at 12 months according to the WHO Child Growth Standards of human milk fed infants.
In one embodiment according to the present invention i) a balanced growth trajectory or body development in an infant is promoted and/or an unbalanced growth trajectory or body development in an infant is prevented or the risk thereof is reduced.
In the graphs in
Diet 1: Standard Nutrilon 1
An infant formula with per 100 ml ready to drink formula 66 kcal, 1.3 g protein (whey protein and casein in a 6/4 w/w ratio), 7.3 g digestible carbohydrates (mainly lactose), 3.4 g fat and 0.8 g short chain galacto-oligosaccharides (source VivinalGOS) and long chain fructo-oligosaccharides (source RaftilinHP) in a 9/1 w/w ratio, and minerals, vitamins trace elements and other micronutrients as known in the art and in compliance with directives for infant formula. The formula is provided as a powder with the instruction to reconstitute with water. About 13.6 g powder was reconstituted to 100 ml ready to drink infant formula.
The lipid globules had a mode diameter, based on volume, of about 5.6 um, and the volume % of lipid globules with a mode between 2 and 12 μm was above 45.
The fat component comprised mainly vegetable fat (blend of palm oil, low erucic acid rape seed oil, coconut oil, high oleic sunflower oil, sunflower oil, a small amount of soy lecithin (0.13 wt. %) and about 1.5 wt. % of an LC-PUFA premix (fish oil and microbial oil).
The lipid globules had a mode diameter, based on volume, of about 0.5 μm, and the volume % of lipid globules with a mode between 2 and 12 μm was below 10.
Diet 2: Experimental Infant Formula
An infant formula similar as diet 1, except for the following: The fat component consisted of about 51 wt. % vegetable fat (blend of low erucic acid rape seed oil, coconut oil, high oleic sunflower oil, sunflower oil), about 44 wt. % bovine anhydrous milk fat, 1.5 wt. % LC-PUFA containing oil (fish oil and microbial oil), 0.13 wt. % soy lecithin, about 3.6 wt. % milk fat derived from buttermilk rich in milk phospholipids or milk fat globule membranes (milk phospholipids are about 1.5 wt. % based on total lipid).
The fatty acid composition is very similar between diet 1 and 2, in saturated, mono unsaturated and poly unsaturated acids, and in n3 and n6 PUFA content. The amount of palmitic acid was 18.4 wt. % and 17.7 wt. % (based on total fatty acids) for diet 1 and 2, respectively. For diet 2 about 36 wt. % of the palmitic acid residues was in the sn2 position, for diet 1 this was about 13 wt. %. The amount of C4:0 (butyric acid) was 0.10 wt. % in diet 1 and 1.39 wt. % in diet 2, C6:0 (caproic acid) was 0.24 wt. % in diet 1 and 0.98 wt. % in diet 2. The wt. % are based on total lipid in the infant formula.
After parent(s)/legal guardian(s) have signed informed consent, exclusively formula fed infants eligible for participation were randomised to receive either the experimental product or the control product for a double-blind period of maximally 17 weeks (depending on their age at study entry). Exclusively breastfed infants participated in the reference group and had the same visit schedule and study assessments as the randomised infants. At the first visit, baseline and birth data were collected, and the study product and diaries were provided to the parent(s). Further study visits were conducted at 5, 8, 13 and 17 weeks of age. Information and anthropometrical measurements were collected during the visits. During the visit at 52 weeks (an optional extension of the study), anthropometrical measurements were collected. 4 countries with 17 sites participated, and in total 313 subjects were enrolled; 6 sites in the Netherlands (121 subjects), 3 sites in France (13 subjects), 7 sites in Belgium (158 subjects), and 1 site in Singapore (21 subjects). Of the total of 313 enrolled subjects, 223 were randomised and 88 were included in the breastfed reference group, 2 subjects were screen failures and were consequently not randomised.
The All-Subjects-Treated (AST) data set consisted of all subjects randomised (ASR, n=223) who received at least some study product. Subjects (n=8) with sufficient evidence that no study product was consumed were considered as non-treated, and were not included in the AST group (n=215).
The ITT data set consisted of all subjects from the ASR group (ITT=ASR). Results from the ITT analysis reflect the effects on the targeted population in a real clinical situation/estimates the effect (effectiveness) of the treatment policy. Subjects' data were analysed ‘as randomised’.
The Per-Protocol (PP) analysis restricts the analysis to the subjects who fulfil the protocol in the terms of the eligibility, interventions, instructions/restrictions and outcome assessment. The PP data set consisted of all subjects and/or subjects' visits from the ITT data set without any major protocol deviations. Thus, the PP dataset was not limited to subjects who completed the study, and the number of subjects per visits varies. Results from the PP analysis estimate the effect (efficacy) of the treatment. Subjects' data were analysed ‘as treated’. The following rules have been applied for exclusion of subjects from the PP data set: Age at baseline (=visit 1) >35 days, birth weight missing or is <9.96th or >90.04th percentile (based on WHO Child growth standard references), Head circumference at inclusion is outside±2.04 SD percentile (based on WHO Child growth standard references), not having at least one valid post-baseline visit. Study product consumption started≥6 days after baseline, having received a different study product as his/her twin sibling, no study product was consumed, relevant medical history, i.e. illnesses/conditions as identified by the Medical Monitor. The following rules have been applied for exclusion of distinct visits from the PP data set: Any visit>3 days after stop of study product intake, regardless if stop was temporarily or not, any visit>3 days after start of other formula feeding, any visit>3 days after start of solid feeding. 49 randomised subjects plus certain visits were excluded.
For the non-randomised breastfed reference group data sets corresponding to the ITT and PP populations of the randomised infants have been defined, too. Correspondingly to the ITT data set, a full breast fed group (FBF) has been defined, no breast fed subjects were excluded. Correspondingly to the PP dataset, a Protocol Compliant Breastfed Reference (PCBF*) data set has been defined, applying the relevant rules as defined for the PP dataset. The following rules have been applied for exclusion of subjects from the PCBF data set: Age at baseline>35 days, birth weight missing or is <9.96th or >90.04th percentile (based on WHO Child growth standard references), Head circumference at inclusion is outside±2.04 SD (based on WHO Child growth standard references), not having at least one valid post-baseline visit, or relevant medical history, i.e. illnesses/conditions as identified by the Medical Monitor. The following rules have been applied for exclusion of distinct visits from the PCBF data set: Any visit>3 days after stop of breastfeeding, in case stop of breastfeeding occurred before 13 weeks of age, any visit>3 days after start of other formula feeding, in case start of other formula feeding occurred before 13 weeks of age, any visit>3 days after start of solid feeding, in case start of other solid feeding occurred before visit 4. 11 breastfed subjects plus certain visits were excluded.
Subjects (either randomised or breastfed) who were included in PP/PCBF dataset up and including visit at 17 weeks of age and participated in the optional extension, were included in PP dataset at visit at 52 weeks.
There were no statistical significant differences between the intervention groups within different dataset (PP, ITT) on the stratification factors sex, age at baseline (<14 days/>14 days), regions (Europe vs. Asia). There was no difference in the duration in the study between the intervention groups.
The analysis of growth (weight and BMI at 52 weeks) was performed using parametric growth curves (PGC), correcting for the stratification factors described above. This approach assumes a parametric function of time (i.e. age of subject) and thus, describes the development of growth parameters (i.e. weight, BMI) over time by a second order polynomial function. It does not require the study subjects to be measured at the same set of time points. The resulting parameters are compared to assess differences between the curves. Sensitivity analyses to confirm model suitability were performed using General Linear Modelling (ANCOVA) and Arbitrary Mean Models, where time modelled as a categorical variable.
For the analysis of z-scores, each anthropometric measurement of subjects was normalized by using WHO Child growth standard z-score references which are age and gender dependent standardised values. A SAS macro (provided by WHO, http://www.who.int/childgrowth/software/en/) was used while normalizing the absolute anthropometric measurements of subjects, no correction for the stratification factors was performed. The analysis of z-scores was performed by age-category, selecting anthropometrical data collected within a window of ±10 days around a visit, taking the real age of the subjects into account. Age-categories are: Birth, 10±10 days at study entry, 35±10 days at week 5, 56±10 days at week 8, 91±10 days at week 13, 119±10 days at week 17, and 365±10 days at 52 weeks.
To conclude equivalence of weight gain from baseline visit (randomisation) until the age of 17 weeks in infants receiving the experimental product compared to infants receiving the control product, the two-sided 90% confidence intervals for the differences in mean weight gain should lie entirely between −0.5 SD and +0.5 SD margins, with a minimum of 3 g/d and a maximum of 5 g/d. The equivalence analysis was performed using parametric growth curves, correcting for the stratification factors described above. This approach assumes a parametric function of time (i.e. age of subject) and thus, describes the development of growth parameters (i.e. weight) over time by a second order polynomial function. It does not require the study subjects to be measured at the same set of time points. The resulting parameters are compared to assess differences between the curves. Sensitivity analyses to confirm model suitability were performed using General Linear Modelling (ANCOVA) and Arbitrary Mean Models, where time modelled as a categorical variable.
Weight
The median weight (kg) of boys and of girls (included in the three study groups) was shown to be well within the z-score of −1 and +1 of the WHO Child growth standard z-scores, for the ITT and for the PP dataset (data not shown).
The weight gain per day in the experimental group was equivalent compared to the breastfed reference group (post hoc analysis) from visit at baseline until the age of 17 weeks, in the PP as well in the ITT datasets, using an equivalence margin of ±3 g/day. Equivalence of weight gain per day was demonstrated for the experimental formula compared to standard formula group (PP and ITT population), even when only selecting infants enrolled before 14 days of age.
The mean weight-for-age z-scores per visit and the corresponding 95% Confidence intervals (CI), showed that the growth in weight of the breastfed reference group was not different from the WHO Child growth standards. Between baseline and 13 weeks of age, the control group and experimental group showed a lower weight-for age z score than the WHO child growth standards for breastfed infants. For the ITT group the z scores of the experimental group were closer to the breast fed group, but the no statistical significant difference was suggested between the two groups (data not shown). At 17 weeks of age there were no statistically significant differences between the experimental or the control group and the WHO Child growth standards. In contrast, at 52 weeks of age the control group showed a significantly higher weight-for-age z-score compared to the WHO Child growth standards for breast fed infants. The experimental group was in particular at 52 weeks more similar to the breastfed reference group as indicated by the overlapping CI and for both groups there was no suggestion for a difference from the WHO Child growth standards.
Interestingly, although the effects were present both for girls and boys, the highest effect was observed for boys, both for PP and ITT group (data not shown).
At 52 weeks of age, the difference in weight between the study groups was compared using a PGC analysis, considering the overall study period (baseline until 52 weeks) and correcting for stratification factors. The results (in gram, for the overall period) as shown in Table 1 reveal that both for ITT and PP datasets the group that received the control formula has a higher weight, but no statistically significant different weight compared to the group receiving the experimental formula. However, the comparison of the control group with the breastfed reference group reveals a statistically significant higher weight in the control group for ITT and PP datasets, respectively (estimate of weight difference control vs. breastfed 551.09 g (p=0.0009) for ITT and 593.03 g (p=0.0009) for PP). The comparison of the experimental group with the breastfeed reference group showed higher weight in the experimental group, which was not statistically different for the PP dataset (estimate of weight difference 254.89 (p=0.1027). Compared to the control group, the experimental group was closer to the breast fed group.
BMI
The median BMI for boys and for girls included in the three study groups was well within the z-score of −1 and +1 of the WHO Child growth standard z-scores, for the ITT and the PP dataset (data not shown).
The mean BMI-for-age z scores and the corresponding 95% Confidence intervals, showed that the growth in BMI of the breastfed reference group was not different from the WHO Child growth standards. For the ITT group at 17 weeks of age there was no statistical significant difference between the control group and the WHO Child growth standards, whereas the BMI z-score of the experimental group was lower and statistically significantly different compared to the WHO Child growth standards. In contrast, at 52 weeks of age the control group showed a significantly higher BMI-for-age z score compared to the WHO Child growth standards off breastfed infants The experimental group on the other hand was more similar to the breastfed reference group as indicated by the overlapping CI and for both groups there was no significant difference from the WHO Child growth standards.
At 52 weeks of age, the difference in BMI between the study groups was compared using a PGC analysis, considering the overall study period (baseline until 12 months) and correcting for stratification factors. The results as shown in Table 2 reveal that both for ITT and PP datasets the group that received the control formula had the highest BMI, which was statistically significant different compared to the group receiving the experimental formula and compared to the breastfed reference group. The comparison of the experimental group with the breastfeed reference group showed higher, but not statistically significant different BMI in the experimental group, neither for the ITT nor the PP dataset.
Weight-for-Length
The median weight-for-length of boys and girls (included in the three study groups was well within the z-score of −1 and +1 of the WHO Child growth standard z-scores, for the ITT and the PP dataset (data not shown).
In line with BMI-for age z-scores, none of the study group reveals a weight-for-length z-score at birth which was significantly different from the WHO Child growth standards. The mean weight-for-length z-scores of the experimental group was slightly lower and significantly different from the WHO Child growth at 17 weeks of age.
At 52 weeks of age there were not differences between the experimental group and the WHO Child growth standards anymore. On the contrary the mean weight-for-length z-scores of the control group at 52 weeks age was higher and significantly different from the WHO Child growth standards.
Interestingly, although the effects were present both for girls and boys, the highest effect was observed for boys, both for PP and ITT group (data not shown).
It should be noted that the difference between the control formula and the breastfed reference group are in line with the observations found in in the scientific literature when comparing breast fed infants with formula fed infants (Dewey et al., 1993, Am J Clin Nutr 57: 140-145).
All mean values (for weight, BMI, weight for length, head circumference and skin folds) are well within the range of normal, healthy infants who are not at risk of obesity.
Skinfold Thickness and Head Circumference
Skinfold thickness is a non invasive measurement of body fat in infants and is an indication of the body development. At 52 weeks the biceps, triceps, suprailiac and subscapular skinfolds were determined, as well as the sum of these skinfolds. The skinfolds of the breast fed reference group (ITT) were lower in case of the biceps, triceps, suprailiac and sum of skinfolds, and were higher for the subscapular skinfold when compared with the control group. In all cases the skinfolds of the experimental group was intermediate, and closer to the breast fed reference group than the control group. The triceps and subscapular skinfold z score of the breast fed reference group was closest to the WHO Child growth standard of human milk infants, and also all the skinfolds in the experimental group were closer to the WHO Child growth standard than the control group.
Also the head circumference-by-age z-score of the experimental group (ITT) was very similar to that of the breastfed reference group, and similar to the WHO Child growth standard of breast fed infants. The z score of the control group (ITT) on the other hand was higher at 12 months of age than the other two groups and was significantly higher that the WHO Child growth standard.
These results are indicative for an effect of formula for infants on promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is similar to the growth trajectory or body development observed in human milk fed infants and/or on promoting a postnatal growth trajectory or body development in an infant towards a growth trajectory or body development which is closer to the optimal growth trajectory or body development of the WHO Child Growth Standards of human milk fed infants. Also these results are indicative for an effect of formula for infants on improving the postnatal growth trajectory or body development in an infant towards the growth trajectory or body development observed in human milk fed infants, in particular when compared to the growth trajectory or body development in infants fed infant formula of follow on formula comprising lipid globules of about 0.5 μm and that do not have a coating of phospholipids. Further these results are indicative for an effect of formula for infants on promoting a balanced growth trajectory or body development in an infant and/or preventing or reducing the risk of an unbalanced growth trajectory or body development in an infant.
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| Number | Date | Country | |
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| 20180296481 A1 | Oct 2018 | US |
