Experts Article

Good nutrition during infancy and early childhood is vital for healthy brain development and physical growth. Fatty acids in breast milk and infant formulas such as docosahexaenoic acid (DHA) and arachidonic acid (AA) contribute to the healthy development of children in various ways such as better cognitive development, visual acuity, immunity etc. The present article outlines the recent guidelines that suggest optimum levels of DHA and AA in an infant formula.

Infancy and early childhood provide a critical window of opportunity for ensuring children’s appropriate growth and development through adequate nutrition. World Health Organization (WHO) recommends that infants should be exclusively breastfed for the first 6 months of life and thereafter receive nutritionally adequate and safe complementary foods (solids and liquids other than breast milk or infant formula) while continuing breastfeeding for up to 2 years of age or beyond.

Importance of DHA and AA

The long chain poly-unsaturated fatty acids (LC-PUFAs) are structural components of all tissues and indispensable for cell membrane synthesis. It is evident that omega-3 fatty acids such as DHA (22:6 n-3) and omega-6 fatty acids such as AA (20:4 n-6), the main LC-PUFA in breast milk, are essential for healthy visual and cognitive development. It is important to note that DHA and AA accumulate in the brain and eye tissue of babies before birth especially during the last trimester of pregnancy. Studies indicate that the DHA content in human milk is quite variable and completely dependent on maternal DHA intake reaching high levels in populations with high marine food consumption. However, DHA-rich food consumption can be challenging in Indian population which largely consumes cereal-based diets with little or no seafood, meaning our daily diet may not necessarily include DHA-rich food.

DHA addition in the diet of term infants helps higher mental scores, higher psychomotor developmental scores, and better problem-solving skills. Looking at the benefits of DHA -AA consumption and worldwide variable dietary habits, several infant formulas are now enriched with pre-formed DHA and AA in addition to the added alpha-linolenic and linoleic acids. The addition of DHA and AA, however, has to be in accordance with the guidelines which have been set for infant formulas. Following are the recent guidelines framed for infant formulations:

Scientific evidence based guidelines

Codex Alimentarius, 2015

According to 2001 WHO report, the infant formula prepared in accordance with applicable Codex Alimentarius standards is safe and a suitable breast milk substitute. Moreover, in 2003, the WHO and UNICEF published their Global Strategy for Infant and Young Child Feeding, which restated that the processed food for infants or the infant formula should meet applicable standards recommended by the Codex Alimentarius Commission.

The revised standards by Codex Alimentarius (2015) recommend that the AA addition is optional and not required when DHA is added. However, if AA is added to infant formula its contents should reach at least the same concentration as DHA i.e. the target DHA:AA ratio in infant formula should be at least 1:1. However, the Codex Alimentarius Commission also suggests that the National authorities may deviate from the above conditions as appropriate for the nutritional needs, based on the differences in regional data for infant and maternal nutrition.

European Food Safety Authority (EFSA 2014)

Based on the scientific analysis and available existing evidence EFSA (2014) in their guideline proposes that DHA (but not more than total n-6 LC-PUFAS) should be added to infant formula, for following reasons:

DHA is an essential structural component of the nervous tissue and the retina and is involved in normal brain and visual development.

• The developing brain has to accumulate large amounts of DHA in the first two years of life.
• Although DHA can be synthesized in the body from a-linolenic acid (ALA), this DHA status more closely resembles that of a breastfed infant than is achieved with ALA alone.
• So far, there is no convincing evidence that the addition of DHA to infant formula has benefits beyond infancy on any functional outcomes. Also, there is a lack of long-term follow-up data on the cognitive and behavioral function from clinical trials which added DHA to infant formula.

The panel further mentions that the infant formulas which add DHA alone, (not AA) are not associated with a decrease in concentrations of AA in the brain and hence there are no direct functional consequences observed with respect to growth and neurodevelopment. Therefore, the Panel considers that there is no need to add AA to infant formula even in the presence of DHA.

As the content of EPA in breast milk is usually low, the guidelines advise that the EPA to DHA ratio should be kept below 1. However, there are no risks reported which investigated any potential health risk with high intakes of EPA in infants.

European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN, 2005)

ESPGHAN published its guidelines last in 2005 which suggests that addition of DHA should not exceed > 0.5% of total fat intake, AA contents should be added in at least 1:1 ratio to the concentration of DHA. Post 2005, no new guidelines have been published for infant formulations by ESPGHAN.

Overall, the recent evidence-based guidelines suggest that the addition of AA to infant formula in the presence of DHA is optional. Whereas, DHA levels that are similar to the breast milk can help in better nutritional benefits such as cognitive, visual and immune system development.