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6 November 2019 - Nutraingredients - Child nutrition experts make case for fatty acid rethink in infant formula

Will Chu

formula milk

The European Academy of Paediatrics and the Child Health Foundation recommend that breast milk substitutes should contain equal amounts of omega 3 and omega 6.


Breastmilk provides the ideal nutrition for babies for the first 6 months of life, as recommended by the W.H.O and other health authorities. In terms of scientific evidence, there is absolutely no debate about this.

In practice, however, most babies in developed countries are now fed partially if not exclusively with infant formula - and there does still remain debate about what fats this should contain. 

The omega-3 and omega-6 fats are both absolutely essential nutrients - but while human breastmilk contains the important long-chain forms of these essential fats ready-made (omega-3 DHA and omega-6 AA), some infant formula still contains only the shorter-chain versions (omega-3 ALA and omega-6 LA).

Evidence has accumulated for decades now to show that providing both AA and DHA pre-formed in infant formula is a good idea. However, the focus of most randomised controlled trials has been primarily on omega-3 DHA.  Some very early trials found that adding DHA without AA appeared to stunt babies' growth - so clinical trials ever since have included a basic amount of AA along with DHA. Their focus, however, has been on outcomes most relevant to DHA (like vision and 'cognitive' development), so these trials would not be capable of detecting likely effects of AA deficiency.

Unfortunately - this lack of clinical trials focusing specifically on omega-6 AA meant that the EFSA review of infant formula made the fundamental error of mistaking 'absence of evidence' for 'evidence of absence'. They concluded that AA is not needed in infant formula simply because there were no trials to show otherwise. 

When EFSA first published their recommendation (several years ago now - but with the implications not due to come into force until 2020), the world's expert scientists and clinicians in this area very quickly pointed out why this was a major error of judgement.  They all emphasised that adding DHA without AA to infant formula could actually be dangerous, and lead to increased risks for serious disability.  (This is because consuming high amounts of the long-chain fats from one series can suppress production within the body of the other series).

To be very clear - the expert consensus is not that adding omega-3 DHA preformed to infant formula is NOT a good idea - because it is. But the key point is that omega-6 AA is also needed, together with omega-3 DHA - just in the same way that both of them are found together in breastmilk. 
  • For articles explaining how and why high levels of DHA are essential for infant brain health, see here
  • For more on the omega-3/omega-6 balance see here.
  • And for a recent and comprehensive review on the importance of AA in infant nutrition, see:
For details of this latest research, aimed once again at persuading EFSA to reconsider its ill-informed recommendation, see:

And for earlier research on this important subject, see:

In a position paper, the European Academy of Paediatrics and the Child Health Foundation argue for the addition of the omega-6 fatty acid arachidonic acid (AA) of which there is currently no obligation.

The paper also wants to see the addition of AA in equal amounts to the omega-3 fatty acid docosahexaenoic acid (DHA) that the new standards say must be added to formula at concentrations 2-3 times higher than typically found in human milk.

“In contrast to the formula composition proposed by the new EU legislation, breastmilk always provides both DHA and arachidonic acid, with mean arachidonic acid levels being higher (0.5% of fat) than those of DHA (0.3%), the experts say in a joint statement.

“Formula with high DHA but low arachidonic acid concentrations induced attenuated results of child development tests up to the age of 9 years.

“[The experts] strongly recommend providing infants, who are not or not fully breastfed, with infant formula that supplies both DHA and arachidonic acid, with at least the same amount of arachidonic acid as of DHA,” the experts add.

Formulas with such a composition more similar to human milk have been shown to be suitable and safe in numerous studies and have been widely used for more than 20 years.”

Countdown to Feb 2020

The paper refers to impending regulatory standards (Commission Delegated Regulation 2016/127) for the EU, which state that from February 2020 onwards, these products marketed in the EU must contain 20–50 milligrams (mg) omega-3 DHA (22:6 Omega–3) per 100 kilocalories (kcal).

The amount represents around 0.5–1% of fatty acids and is higher than typically found in human milk and current infant formula products.

However, concerns are raised on this novel composition of formula for infants as suitability and safety has not been established in clinical studies.

The paper points out that reviewed studies suggest high DHA intakes without balanced amounts of AA may induce undesirable effects in infants, such as reduced AA concentrations in brain tissue and suboptimal neurodevelopment.

Its authors go on to recommend that infants should not be fed formula with high DHA contents but without AA unless a thorough evaluation has been performed and evaluated by independent scientific experts.

More research needed

Breast-milk DHA in high fish-eating regions such as Japan may contain more than 1% DHA, the paper concludes.

Formulae that replicate these higher DHA amounts and with AA amounts more than 0.7% AA have not been tested; these should be clinically evaluated before market introduction.

“Well-designed clinical studies should evaluate the optimal intakes of DHA and AA in infants at different ages based on relevant outcomes, such as safety, growth, neurodevelopment, and immune development.

“The second half of the first year of life deserves specific attention because common weaning foods during this period generally provide only small amounts of DHA and AA.

“We recommend investment of public research funding to enable the execution of adequately designed and powered clinical studies.”