Milk as a Carrier of Fortification

Key Messages

• There are good data to show that pre­school children, especially those in the 1- to 3-year age bracket, are at risk of inadequate intakes of a number of important vitamins and minerals, no­tably iron and vitamin D
• Ultimately, nutritional education and securing better supply and availability of appropriate foods should address this important issue
• Nevertheless, until that can be achieved, there is good evidence to show that fortified milk, including young child formulas, can make a sig­nificant contribution to an appropriate nutrient intake at this important time in a child’s growth and development

Children aged between about 1 and 3 years are undergoing a significant pe­riod of nutritional transition from a milk-based diet, be that breast milk or an appropriate infant formula, to the con­sumption of an increasing amount and variety of family foods. This period is, however, a time when many children are at risk of inadequate nutrient sup­ply especially in developing countries and disadvantaged populations in other countries. Moreover, neophobia (i.e., hesitancy to try new foods) and/or “picky eating” are also common at this time [1].

Young child formulas (YCF) have been marketed since around 1990 and are often seen as a solution to pre­venting inadequate nutrient supply in such children. The need for YCF is not universally accepted, as it is believed by many that the nutritional needs of children aged 1 to 3 years can be eas­ily covered by a “balanced diet,” at no extra financial cost to families, and in an ideal world, this would be the case. Nevertheless, a recent review assessed the literature for available ev­idence of dietary nutrient intakes rela­tive to reference nutrient intake across the globe [2]. Twenty-three publica­tions from 19 different countries, including both developed and develop­ing countries, met the review criteria. The authors concluded that many nutrients were often limited in many children, from many countries, notably vitamins A, D, B₁₂, and C, folate, cal­cium, zinc, iron, iodine, and docosa-hexaenoic acid.

Matsuyama et al. [3] undertook a systematic review and meta-analysis of randomised controlled trials of what they referred to as “fortified milks,” which included YCF, against control milks, which was often standard cow’s milk. Fifteen articles sourced from 5 major international databases met the eligibility criteria that included that the population studied be otherwise healthy children aged between 6 and 47 months and that outcomes were growth parameters and biochemical markers. The use of fortified milk com­pared with control milk had a small nonsignificant effect on body weight gain over the study period (mean dif­ference = 0.17 kg; 95% CI: 0.02–0.31 kg). However, it is noteworthy that the risk of anaemia was reduced in the fortified milk groups (OR = 0.32; 95% CI: 0.15–0.66). Iron deficiency, which can lead to anaemia, is reported as be­ing the most common micronutrient deficiency in the world [4]; and so, clearly many young children are not re­ceiving adequate amounts of dietary iron. As noted by Matsuyama et al. [3], efforts to raise public awareness of the importance of iron-rich complemen­tary foods are essential. Nevertheless, availability of such foods can be scarce in some developing countries.

Very recently in 2018, the results of a randomised controlled trial of a YCF versus cow’s milk in Australia and New Zealand have been reported [5]. After having consumed either the YCF or cow’s milk for 12 months between the ages of 1 and 2 years, the YCF group had a lower total protein intake and higher iron, vitamin D, vitamin C, and zinc intake at 2 years of age with the differences for iron, vitamin C, and vi­tamin D reaching statistical signifi - cance. As reported by Suthutvoravut et al. [2], micronutrient deficiencies in young children are widespread, and whilst nutritional education and avail­ability of appropriate foods are the key to overcoming this global problem, as was concluded by Matsuyama et al. [3], there is evidence that fortified milk can be effective also, under certain circum­stances.