This document discusses opportunities in infant nutrition, specifically focusing on leveraging functional benefits. It notes opportunities in preterm nutrition, specialized nutrition for IUGR babies, and complementary foods from 6-24 months. Functional benefits discussed include growth and development, digestion, immunity, allergy prevention and management. The document then discusses various immunonutrients like fatty acids, vitamins A, C, E, iron, zinc, nucleotides, probiotics and their roles and mechanisms in supporting immune function. It notes evidence from studies on the positive impacts these nutrients can have on immune responses and reduction of infections. The document concludes by acknowledging some of the challenges to nutritional solutions like activism, outdated regulations and guidelines, and issues around sanitation and clean drinking water

1. Leveraging Opportunities in
Infant Nutrition
Dr. Sanjeev Ganguly
Medical Director-South Asia
Nestle Nutrition

2. Top 10 countries for numbers of stillbirths,
neonatal and maternal deaths
Ranking for neonatal Ranking for Ranking for
deaths maternal deaths stillbirths
India 1 1 1
Nigeria 2 2 3
Pakistan 3 1.5 million 8 178,000 2 1.77
China 4 neonatal 13 maternal 8 million
deaths deaths stillbirths
DR Congo 5 3 6
Ethiopia 6 Approx 5 Approx 5 Approx
67% 65% 63%
Bangladesh 7 6 4
of global of global of global
Indonesia 8 total 7 total 7 total
Afghanistan 9 4 12
Tanzania 10 9 11
Ref: Lawn JE et al BJOG sept 2009. Data sources: Estimates of maternal (2005) and neonatal (2008) deaths from WHO. Stillbirths from Cousens et al 2010 Updated Aug 2010

3. We live in a World with Large
Inequalities
Population
Income

4. Germany: The Melander family of Bargteheide
Food expenditure for one week US $500

5. Ecuador: The Ayme family of Tingo
Food expenditure for one week US $31.55

6. Chad: The Aboubakar family of Breidjing Camp
Food expenditure for one week US $1.23

7. India
• One of the most malnourished countries in the World.
• > 40% of the World’s under weight children below five years live in India
(Global Hunger Index 2007)
• The NFHS 3 - not much progress achieved in improving human resources.
• Poverty is a major, but not the only cause of malnutrition
• Percentage of population suffering from various forms of malnutrition, far
exceeds the percentage below poverty line
• After National Nutrition Policy 1993 and National Plan of Action, 1995 no
national programs or policies for eradicating malnutrition have appeared.
• Today, no national program specifically to combat malnutrition

8. Nutrition Interventions
• Coverage of essential nutrition interventions is
low ~ 30-40% (Menon2009)
• ICDS: new evidence to show positive impacts, but
could be much more efficient (Kandpal2011)
• MMS: good impacts on nutrition (Singh 2008), but
wrong age group (4-5 year olds) for early under
nutrition
• ASHA: promising (Ved2011) but no impact studies
yet and recruitment and support systems need
strengthening

9. Facts :
• More than 4 out of every 10 children in Mumbai, Meerut,
and Delhi are stunted.
• Underweight is much more prevalent in slum areas than non-
slum areas
• More than half (54 percent) of all deaths before age five
years in India are related to malnutrition.
• Because of its extensive prevalence in India, mild to
moderate malnutrition contributes to more deaths (43
percent) than severe malnutrition (11 percent).
• Seven out of every 10 children age 6-59 months in India are
anaemic.

10. Trends in Malnutrition Among Children
Under Three Years

11. Poor Nutrition as a Contributing Factor to
Under-Five Mortality

12. Inter-generational Cycle of Malnutrition and Ill Health
•No excl. BF
•Poor fetal nutrition
•Delayed /Poor
•Poor mother nutrition
complementary feeding
•No / poor
Low Birth •Inadequate food
supplementation Weight •Infection & healthcare
•Gender discrimination
•Poor growth catch-up
•Infection & healthcare
N
U
T
Malnourished R
I Stunted Child
Mother T
I
O
N
•Early Marriage •Poverty
•Poor Nutrition •Poor Nutrition
•Short inter-pregnancy •Awareness & Education
Malnourished Girl
gap •Infection & Healthcare
•Low BMI facility
•Gender discrimination •Gender discrimination
Courtsey : Veena S Rao

13. Opportunities
• Preterm Nutrition
– In NICU
– Post Discharge
– HMF
• Especialized Nutrition for IUGR babies ?
• 0-6 months – Infant Formula
• 6-24 months
– Follow up formula
– Complementary foods

14. Opportunities – Functional
Benefits
• Growth & Development
• Digestion
• Immunity
• Allergy Prevention
• Allergy Management

15. ROLE OF IMMUNONUTRIENTS

16. IMPACT OF NUTRITIONAL
DEFICIENCY ON IMMUNITY
• Nutritional deficiency is commonly associated
with impaired immune responses, especially
cell-mediated immunity, cytokine production,
secretory antibody response and affinity
• The proper consumption and absorption of
micronutrients (e.g. zinc, iron, selenium,
vitamin A, pyridoxine, vitamin E) is essential
for optimal immune responses

17. ROLE OF NUTRIENTS ON IMMUNE SYSTEM
• The immune system is undergoing permanent renewal
and produces millions of immune cells daily. Immune
cell renewal is elevated during infectious disease, and
recovery depends on the rate of cell division between
the invading microorganism and that of immune cells.
• The immune system uses both macro and
micronutrients involved in DNA, RNA and protein
synthesis.
• Under-nutrition has a strong influence on the immune
system at all ages but mainly in growing and aged
humans, i.e. when the body’s nutritional reserves are
limited.

18. FATTY ACIDS AND THE IMMUNE SYSTEM
• Feeding EPA and DHA has been shown to
modulate specific functions of innate and
acquired immunity.
• Feeding high levels (>10% of total fat) of n-3 PUFA
(compared with diets high in n-6 PUFA) to healthy
animals or human subjects results in suppression
of the ability of lymphocytes to respond to
mitogen stimulation, NK cell activity, and delayed-
type hypersensitivity (DTH) reactions

19. MECHANISMS RESPONSIBLE FOR THE ROLE OF
LONG CHAIN N-3 PUFA ON IMMUNE FUNCTION

20. • compared with Formula-fed infants, the Formula+LCP
infants had a higher % of CD3+CD44+and CD4+CD28+
cells and cytokine profile (lower production of TNF-a post-
stimulation) that did not differ from HM infants.
• “feeding infants formula during the first 10 d of life
influenced immune function… infants had a higher
percentage of CD3+, CD4+CD28+, and lower percentage
of CD14+ cells and produced more TNF-a and interferon-g
after PHA stimulation than HM-fed infants (P,0·05).

21. VITAMIN A AND THE IMMUNE SYSTEM
• The importance of vitamin A in immune
function and protection against infections is
well-established
• Vitamin A deficiency can affect host defenses
directly through its essential functions in
metabolism in the various immune cells or
indirectly through its role in epithelial cell
differentiation and host barrier function

22. VITAMIN A AND THE IMMUNE SYSTEM
• Vitamin A supplements has been found to
improve the antibody titer response to
measles vaccines, maintain gut integrity, lower
the incidence of respiratory tract infections,
and reduce mortality associated with diarrhea
and measles

23. MECHANISMS RESPONSIBLE FOR THE ROLE
OF VITAMIN A ON IMMUNE FUNCTION

24. • “43 randomized trials representing 215,633
children, shows that giving vitamin A capsules
to children aged 6 months to 5 years can
reduce death and some diseases”
• “death due to measles, respiratory infections
or meningitis was not specifically reduced, but
vitamin A can reduce new occurrences of
diarrhoea and measles”

25. IRON AND IMMUNE SYSTEM
• Iron regulates the function of T lymphocytes, and
in most studies (in vivo and in vitro), a deficiency
results in impaired cell-mediated immunity.
• Iron deficiency may also delay the development
of cell-mediated immunity
• Neutrophil function (decreased myeloperoxidase
activity and bactericidal activity) and NK activity
are impaired with iron deficiency

26. MECHANISMS RESPONSIBLE FOR THE
ROLE OF IRON ON IMMUNE FUNCTION

27. • “Significantly lower levels of T lymphocytes as
well as CD4+ cells was observed in the iron
deficient children (P<0.01 and 0.002
respectively). The CD4 : CD8 ratio was also
significantly lower in this group (P<0.05)”
• “Iron supplementation improved the CD4
counts significantly”

28. ZINC AND IMMUNE SYSTEM
• Zn deficiency impedes host-defense systems
leading to increased susceptibility to a variety
of pathogens, and a deficiency of Zn is known
to occur in many diseased states that involve
the immune system like alcoholism, renal
disease, burns, gastrointestinal tract disorders
and diarrhea

29. MECHANISMS RESPONSIBLE FOR
THE ROLE OF ZINC ON IMMUNE FUNCTION

30. • “Children who received a zinc supplement had fewer
episodes of diarrhea (rate ratio: 0.86) and respiratory
tract infections (rate ratio: 0.92) and significantly fewer
attacks of severe diarrhea or dysentery (rate ratio:
0.85), persistent diarrhea (rate ratio: 0.75), and lower
respiratory tract infection or pneumonia (rate ratio:
0.80) than did those who received placebo. They also
had significantly fewer total days with diarrhea (rate
ratio: 0.86)”

31. • “Zinc supplementation decreased the proportion
of diarrhoeal episodes which lasted beyond 7
days, risk of hospitalization, all-cause mortality
and diarrhoea mortality”
• “…zinc for the treatment of diarrhoea is
estimated to decrease diarrhoea mortality by
23%”

32. • “six trials and 7850 participants ….analysis
showed that zinc supplementation reduced the
incidence of pneumonia by 13% and prevalence
of pneumonia by 41%”
• “subgroup analysis…zinc reduced the incidence of
pneumonia defined by specific clinical criteria by
21%”

33. NUCLEOTIDES AND IMMUNE SYSTEM
• Nucleotides may become conditionally essential during
growth and immunological challenges when demand
may exceed de novo synthetic capacity
• The addition of nucleotides to nucleotide-free diets has
been shown to reverse or restore many of the changes
observed with nucleotide deficiency, such as increasing
Th1-type cytokines, increasing antibody production,
and increasing spleen cell proliferation.
• Human infants fed breast milk or formula
supplemented with nucleotides had higher NK cell
activity and IL-2 production compared with infants fed
formula without nucleotides.

34. MECHANISMS RESPONSIBLE FOR THE ROLE
OF NUCLEOTIDES ON IMMUNE FUNCTION
• Nucleotides contribute to the pool of
nucleotides available to immune cells
• Nucleotides are building blocks for DNA and
RNA synthesis and are involved in diverse
cellular processes, serving as sources of
chemical energy [e.g., 5-triphosphate (ATP)]
and intracellular signals (e.g., adenosine cyclic
3,5-adenosine monophosphate and cyclic 35-
guanosine monophosphate)

35. • Systematic review and meta-analysis showed that
ribonucleotide-supplemented infant formulae were
associated with a better antibody response to
immunisation with Haemopillus influenzae vaccine
[SMD 1·74 (99 %CI 1·43–2·05), P = 0·001], diphtheria
toxoid [SMD 0·94 (0·75–1·12), P = 0·001], oral polio
vaccine [SMD 0·73 (0·51–0·95), P =¼ 0·001], and fewer
episodes of diarrhoea [RR 0·67 (0·58–0·76),P = 0·02]

36. PROBIOTICS AND IMMUNE SYSTEM
• Probiotics are live microbial food
supplements, which beneficially affect the
host by improving its intestinal microbial
balance.
• Recent evidence indicates that probiotics (e.g.
bifidobacterium and Lactobacillus species)
may influence both systemic and gut-
associated immune responses.

37. • “Infants consuming formula with Bb12
produced feces with detectable presence of
Bb12 and augmented sIgA concentration”

38. VITAMIN C AND THE IMMUNE SYSTEM
• Vitamin C is an essential component of every
living cell. Vitamin C is highly concentrated in
leukocytes and is used rapidly during infection
(e.g., to prevent oxidative damage).
• Reduced concentrations of this vitamin in
leukocytes is associated with reduced immune
function

39. MECHANISMS RESPONSIBLE FOR THE ROLE
OF VITAMIN C ON IMMUNE FUNCTION

40. VITAMIN E AND SELENIUM AND
THE IMMUNE SYSTEM
• Vitamin E and the trace element selenium (Se)
function synergistically (by related but
independent mechanisms) in tissues to reduce
damage to lipid membranes by the formation
of reactive oxygen species (ROS) during
infections

41. MECHANISMS RESPONSIBLE FOR THE ROLE OF
VITAMIN E AND SELENIUM ON IMMUNE FUNCTION

42. • Intervention: One year of fortified milk providing
additional 7.8 mg zinc, 9.6 mg iron, 4.2 g
selenium, 0.27 mg copper, 156 g vitamin A, 40.2
mg vitamin C, 7.5 mg vitamin E per day
• Results: Reduced the odds for days with severe
illnesses by 15%, the incidence of diarrhea by
18%, and the incidence of acute lower respiratory
illness by 26%

43. Challenges
• Activism is a major challenge
• Regulations are archaic
– Zn is a contaminant as per Food Laws
– Low levels of protein in Preterms
– IYCF guidelines outdated
• Environmental sanitation & Clean drinking
water
• Generating evidence on Nutritional solutions

44. Thank you