Babies are born with an immature immune system and a nearly sterile gut. Programming of their systemic immunity begins soon after birth and is strongly influenced by the multitude of bacteria that colonize the gut in their first days and weeks to form the body’s microbiota. A healthy gut microbiota is believed to impact health by competing directly with pathogenic bacteria for nutrients and available binding sites on the intestinal epithelium, strengthening the intestinal mucosa barrier, and generating compounds that participate in various metabolic processes.
The immunomodulating effects of the microbiota and its ability to defend against pathogens in food characterize the colon as the largest participant in the body’s immune system. The bacteria that establish themselves early in life play a crucial role in building up host defense against pathogens and disease.
Breast is Best
Breastfeeding confers numerous benefits to babies, among them, a stable and balanced microbiota. Breast milk is naturally high in oligosaccharides that cannot be digested in the small intestine (HMO=human milk oligosaccharides). They travel intact to the colon, where they nourish and are fermented by beneficial bacteria, including bifidobacteria. In this way, breast milk serves as a prebiotic, with its oligosaccharides stimulating the growth and activity of the bacteria that make up the baby’s microbiota. HMO are also called the bifido-factor or bioactive factor in breast milk. It has been shown that the microbiota of babies who are breast fed is dominated by beneficial bifidobacteria (Harmsen et al, 2000; Turroni et al, 2012). In bottle-fed infants this is not the case.
Breastfeeding has been associated with a protective role not only in infancy but throughout life. Breastfed newborns and premature babies are at lower risk of developing infections, diarrhea, and necrotizing enterocolitis (Guaraldi & Salvatori, 2012). Allergic and atopic diseases appear to be less prevalent among children who have been breastfed (van Odijk et al, 2003). In adulthood, a history of being breastfed may confer benefits to bowel and metabolic health.
Inulin-type Fructans and the Microbiota
In various countries around the world, premature babies, infants, and children up to 2 years of age and beyond whose formula was supplemented with inulin-type fructans from chicory root, including a combination of inulin enriched with oligofructose (Orafti® Synergy1 (SYN1)), have been shown to promote the increase of bifidobacteria and develop a bifidobacteria count that more closely resembles that of breastfed infants (See tables that follow for specific study references). Oligofrucose (FOS) or SYN1 are the bifidofactors (bioactive factor) in bottle-fed infants and small children.
Although infant formulas have evolved to resemble the benefits of breast milk nutrition and health, not all formulas contain added prebiotics for building the microbiota. In fact, babies fed traditional non-oligosaccharide-supplemented formula have been shown to have lower bifidobacteria counts than breast fed babies (Closa-Monasterolo et al, 2013).
Childhood constipation is among the most common gastrointestinal complaints in children. Although diagnostic criteria vary, they can involve infrequent bowel movements, pain on defecation, the passing of large, hard stools, and fecal incontinence. The prevalence of functional constipation is estimated to be 3 percent worldwide, with approximately 40 percent of children with functional constipation developing symptoms during the first year of life. Emergency visits for constipation are on the increase; between 2006 and 2011, constipation-related visits to emergency rooms across the U.S. rose 41.5 percent, led by infants and children (Sommers et al, 2015).
Constipation in children typically occurs at three distinct stages: after starting formula or processed foods during infancy, during toilet training in the toddler years, and soon after starting kindergarten. Low fiber intake is among the factors associated with constipation in childhood. An adequate intake of 14g/1000kcal, or ~ 19g/d for children 1-3 years of age and ~ 25g/d for those 4-8 years of age, is recommended to lower risk of constipation (IOM 2005).
Bowel function appears to differ between breast- and formula-fed infants, with formula-fed infants having less frequent and more firm stools (Weaver et al, 1988). The softer (loose) stools of breastfed babies have been attributed to the presence of human milk oligosaccharides in breast milk.
The addition of inulin-type fructans to formula and food has been shown to improve regularity. Metabolites from the fermentation of oligosaccharides increase osmolality in the colon, pulling water into the gut lumen and softening the baby’s stool (Ballard and Morrow, 2013). In a randomized, double-blind, placebo-controlled trial on 56 infants under one year of age, Moore et al (2003) observed an increase in stool frequency from 1.58 to 1.99 times per day and a softened stool consistency after feeding between 0.75 and 3g/day of oligofructose or control (maltodextrin) over 4 weeks.
Supplementation of an average of 1.1 g/day oligofructose decreased constipation in a group of 123 infants and toddlers ages 4-24 months (Saavedra, 2002). Closa-Monasterolo et al (2013) demonstrated in a double-blind, randomized, placebo-controlled and parallel trial comparing infants who were breastfed or given formula supplemented with either SYN1 or a maltodextrin control that the SYN1 infants had a higher stool frequency compared to the control group.
Inulin-type fructans also have been shown to improve bowel consistency. A group of 35 infants and toddlers receiving 2 g/day oligofructose as part of a randomized, double-blind, placebo-controlled intervention study experienced significantly less diarrhea (Waligora-Dupriet et al, 2007). Desirable changes in stool consistency also were observed in a group of 2-5 year-old children with functional constipation (Escribano et al, 2015). Closa-Monasterolo et al (2013), comparing breastfed infants to formula+SYN1 to control, observed the softest stools with breast feeding, followed by SYN1, with stool consistency significantly different from control at all points during the study. A study by Wernimont et al (2014) similarly found that infants receiving oligofructose-supplemented formula most closely resembled breastfed infants in terms of stool consistency.
Inulin and Oligofructose are Safe for Infants, Children
As natural food components, the inulin-type fructans inulin and oligofructose are safe for feeding to infants and small children. They occur naturally in many fruits and vegetables – chicory root is an abundant source – and have been consumed for thousands of years. Food legislations around the world have approved the safe use of inulin and oligofructose in infants and children, acknowledging no difference in normal development and growth, urine electrolyte balance, or blood chemistry parameters, and acknowledging their bifido-supporting, prebiotic effect for infants and small children.
In the U.S., the inulin-type fructan products Orafti®P95 (oligofructose), Orafti®HP (inulin), and Orafti®Synergy1 (oligofructose plus inulin) are GRAS ingredients for use in infant formulas, baby cereals, and other food and beverage products.
Inulin-type fructans can benefit the digestive health of infants and children in numerous ways. They have been shown to help build and support the intestinal microbiota and to improve stool frequency and consistency in a way that resembles bowel movements in breastfed infants.