Pediatric Nutrition in Practice

98 Koletzko^

pert Group co-ordinated by the European Soci-
ety for Paediatric Gastroenterology, Hepatology
and Nutrition (ESPGHAN) [3] ( table 1 ).

Optional Ingredients in Infant Formula

The addition of a variety of optional ingredients
is generally accepted if there are adequate evi-
dence of their safety and indications of a benefit.
While the Codex Alimentarius considered the
addition of the long-chain polyunsaturated fatty
acids docosahexaenoic acid (DHA) and arachi-
donic acid to infant formula an option, recent ex-
pert recommendations considered it advisable to
always provide DHA and arachidonic acid to in-
fants [6, 7] , and recent European Food Safety Au-
thority (EFSA) recommendations for infant for-
mula in Europe advised that all formulae should
contain 20–50 mg DHA/100 kcal [8].
In recent years, many infant formulae have
been marketed with the addition of live bacteria
with proposed beneficial health effects for the re-
cipient infant (probiotic effects), non-digestible
oligosaccharides with proposed beneficial (prebi-
otic) health effects and the combination of probi-
otic and prebiotic (synbiotic) ingredients. Based
on a systematic review, the ESPGHAN concluded
that the use of currently used formula with added
probiotics and/or prebiotics in healthy infants
does not raise safety concerns with regard to
growth and reported adverse effects [9]. However,
the available data were considered insufficient to
recommend the routine use of probiotic or prebi-
otic supplemented formulae. It was emphasized
that there are considerable differences amongst
various probiotic or prebiotic components. There-
fore, the safety and clinical effects of each formu-
la concept should be individually assessed and not
be extrapolated from data on other products.
Thickening agents such as starch or carob bean
g u m have been added to i n fa nt for mu lae ma rketed
as ‘antireflux’ or ‘antiregurgitation’ formulae. The
ESPGHAN advised that there are only limited in-

dications for thickened formulae, which are not

needed for most infants with moderate spitting

and regurgitation who thrive well [10]. However,

the use of thickened formula can be beneficial to

reduce the loss of energy and nutrients in infants

with marked spitting and growth faltering.

Infant Formula Based on Soy Protein Isolate

Infant formula can be based on the milk of cows or

other animals as well as other ingredients suitable

for infant feeding, including soy protein isolate [5].

The digestibility and biological value of soy protein

is lower as compared to cow’s milk protein, and

infant formulae based on soy protein generally re-

quire the addition of some free amino acids. A

higher protein content is required for infant for-

mula based on soy protein compared to cow’s milk

protein ( table 1 ). There is concern on further po-

tential disadvantages due to high contents of phy-

tate, which reduces the bioavailability of some nu-

trients, phytoestrogens (isoflavones), which in-

duce alterations to immune effects in animals, and

aluminium, although the long-term effects of these

components are not known [11]. Soy protein for-

mulae have no benefit for the prevention of allergy

and food intolerance [12]. It is recommended that

soy formula should only be used with a specific in-

dication, such as complete lactose intolerance (ga-

lactosaemia), cow’s milk allergy in infants older

than 6 months, or family convictions such as the

wish to follow a vegan or kosher diet [11].

Infant Formula Based on Protein

Hydrolysates

Therapeutic formulae for infants with cow’s milk

protein allergy that are based on extensive protein

hydrolysates, or crystalline amino acid mixtures,

are considered foods for special medical purposes

and are not intended for use in healthy children.

However, infant formulae for healthy infants with

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 97–103

DOI: 10.1159/000375271