Paediatrics | Omega-3s in Children

The Health Effects of Omega-3s in Childhood

Carrie Ruxton, PhD RD, Freelance Dietitian

Introduction

Very long chain omega-3 polyunsaturated fatty acids,omega-3s for short, have come to the attention of scientists and health professionals during the last couple of decades due to their role in heart health. However, more recently attention has switched to other benefits, including immune programming and support for brain development, which appear to have more relevance to infants and children.This article will consider the evidence from such studies and investigate whether or not UK children are getting enough omega-3s.

What are omega-3s?

Fatty acids are the building blocks of dietary fats, of which there are several types including saturated fats (found mainly in animal fats), monounsaturated fats (found in olive oil) and polyunsaturated fats (found mainly in vegetable oils and fish oils). Omega-3s sit within the family of polyunsaturated fats (Figure 1). Specific examples are alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The term omega refers to the positioning of first double bond in the fatty acid structure. For example, counting from the methyl end, omega-3 (or n3) fatty acids have their first double bond

between the third and fourth carbon atoms in the chain. Omega-3s have a large number of double bonds which lowers their melting point, making them fluid at room temperature. This is one of the key reasons why omega-3s are useful to the brain, as we shall see later. As well as double bonds, the chain length of fatty acids affects the benefits they deliver. Most scientific evidence relates to the very long chain omega-3s, DHA and EPA, with far fewer studies reporting benefits for the shorter-chain omega-3, ALA. Our bodies can metabolise DHA and EPA from the plant-based ALA but the process is inefficient and can be hindered by high intakes of omega-6 fatty acids.1 Therefore, it is far more efficient to consume EPA and DHA directly from dietary sources.

Figure 1: Overview of Dietary Fats

Fats

Monounsaturated

Polyunsaturated

Saturated

e.g. olive oil

Omega 6 Fats

Omega 3 Fats Vegetable sources shorter-chain (ALA) Marine sources, longchain (EPA, DHA)

e.g. sunflower oil

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Omega-3s in Children | Paediatrics

Sources and recommendations

Fish is the principal dietary source of omega-3s, particularly oily fish such as salmon, trout, mackerel, herring and fresh tuna. However, meats and fortified products also contain small amounts of omega-3s. Fish oil supplements are rich in omega-3s, both fish body oil and fish liver oil, the latter offering a source of fat soluble vitamins. Recommendations for omega-3s in the UK are presented as ideal weekly fish intakes, i.e. two portions, one of which should be oily.2 This translates as 0.45g per day of omega-3s. The fish advice is based on an average portion size of 140g and is directed at the whole population. However, no specific guidance was given on portion sizes for children, some of whom may struggle to eat 140g. Further policy development is needed to address this gap. In other countries, omega-3s requirements across the age spectrum have been addressed by various expert bodies. In the US, the Food and Nutrition Board3 suggested around 0.15g per day for pre-school children. In Australia and New Zealand, the National Health and Medical Research Council4 recommended intakes of up to 0.1g per day in children. The World Health Organisation5 suggested intakes of 0.1-0.25g depending upon the age group.

Table One: Fish Intakes in UK Children

Reference No. Children 9 10 7 8 Adolescents 7 8 Age Sample Size Total Fish Intake (g/week) 21 101 35 140 116 109 Intake of Oily Fish (g/week) 17 7 21 14 3 % Oily Fish Consumers 14 10 6 3

6-9 months 3y 2-10y 4-10y 11-18y 11-18y

1131 863 797 238 224 415

Table Two: Key Findings of RCT in Pregnancy

Changes seen in Omega-3 Supplemented Group Risk of infant food allergy reduced. Markers of inflammation showed beneficial changes Reduced risk of IgE-associated eczema in infants with a family history of allergic disease Improved mental development, particularly sequential processing and problem solving Eye and hand coordination improved Increased visual acuity and retinal sensitivity found in infants with a better DHA status Reference No. 17, 18, 19 19 20, 21 22 23, 24, 25

Intakes
Some authors have attempted to assess omega-3 intakes in populations of children. One review6 reported that Australian children consumed 0.034g to 0.095g per day in the two to 11 years age group, and 0.118g to 0.145g in the 11-18 years age group. This is similar to intakes in Belgian pre-school children which were 0.065g to 0.075g.6 Fish consumption is the best predictor of omega-3 intake. A study of over 1000 German children found that daily omega-3 intakes in regular fish consumers were ten times higher than in children who ate no fish (0.10-0.26g vs. 0.01-0.02g). Turning to the UK, there are currently no published analyses of omega-3 s intakes in children. However, data on average weekly fish intakes are provided by the National Diet and Nutrition Survey (NDNS) 7, 8 and the Avon longitudinal survey of children living in the South West of England.9, 10 These are summarised in Table One and show average fish intakes in the total sample, i.e. including non-consumers. It can be seen that younger children consume up to 140g fish per week, while older children consume 116g, but most of this is white fish. Only 14 per cent of pre-schoolers, 10 per cent of young schoolchildren and six per cent of teenagers consume oily fish. Even taking the highest weekly intake of 21g oily fish in four to 10-year olds, this would provide just 0.4g omega3s per week around 13 per cent of the recommended level. These findings are confirmed by a recent telephone survey of 1000 UK parents (One Poll, personal communications). Only 10 per cent of

children ate fish two or more times a week, with 40 per cent eating it once a week, despite the fact that 42 per cent of parents claimed to be aware of the fish recommendations. In addition, 87 per cent of children never consumed oily fish. Barriers to fish consumption included aversion to the flavour, smell and texture, or concerns about bones. Over 19 per cent of parents claimed that their children did not like fish. Fish fingers were the most popular fish dish, eaten by 67 per cent of fish consumers. Salmon was the most preferred oily fish.

Omega-3s and health

Early life
The role of omega-3s in the development and maintenance of the human brain has been recognised for some time. DHA makes up 25% of brain fatty acids11 and seems to drive the rapid growth seen in foetal brain tissue during the last trimester of pregnancy.12 DHA is probably vital for brain development because it creates fluidity in neuronal membranes, thus helping to facilitate enzyme activity, protein binding and nutrient transport, all of which govern how well the brain functions. DHA also has a role to play in the development of vision and accounts for 50% of fatty acids in the retina.13 It is thought that the fluidity of DHA supports the normal functioning of photoreceptor cells, thus helping visual acuity (clarity).14 A poor DHA status during foetal development has been linked with sub-optimal cognitive function and vision.15,16 There is also a role for omega-3s in immune function. Substances in the body called eicosanoids, which are made from fatty acids, control the intensity and duration of inflammatory responses. It is believed that the eicosanoids

produced from EPA are less potent, and thus less inflammatory, than those synthesised from omega-6 fatty acids. This means that maternal diets which are high in EPA can programme foetal immune systems to be less allergic.1 Several randomised, controlled trials (RCT) have tested how maternal omega-3 status influences infant development. The methods for these studies involve pregnant women being randomised to receive either omega-3 supplements or a placebo for several months. Their infants are then tested at a later date for cognitive, retinal and immune function. The results from these trials (Table Two) suggest benefits to infant development at maternal intakes of 0.2 to 3.7g of DHA + EPA. These levels are achievable with recommended weekly intakes of fish, or regular use of commercially-available fish oil supplements. Omega-3s remain important during the first year of life due to the continued high rate of brain development. Trials in term infants are few in number but have tended to report beneficial effects. For example, supplementation of formula milk with omega-3s and arachidonic acid has boosted DHA status,26 improved mental development at 18 months of age,27 improved visual acuity,28, 29 and increased IQ30 towards levels seen in breast-fed infants. A review of the evidence31 suggests that omega-3s produce strong and significant effects on visual acuity in young babies.

School-aged children
Most trials of omega-3s in this age group have focussed on children with behavioural disorders, such as ADHD or dyspraxia. Generally, omega-3 intakes in these trials are 0.3 to 0.6g per day. A systematic review funded by the Food Standards Agency32 concluded that there were some benefits

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Paediatrics | Omega-3s in Children

to supplementing children with ADHD with omega3s but that firm conclusion were hampered by small sample sizes, short studies and a lack of consistency in dosages. Of more relevance is the limited, but growing, number of studies in normal, healthy children. Six of these have been published since 2002 (Table Three). The two earlier studies33, 34 used fortified foods, which resulted in a wide range of omega3 intakes and inconsistent findings. The later four studies were better controlled but found no major impact on mental performance tests. However, some positive effects in the omega-3 groups were found which could, over time, impact on health or performance, e.g. improved DHA/EPA status, more normal immune function, better verbal learning and memory, improved performance in listening comprehension and vocabulary acquisition tests. Significant reductions in inattention and undesirable behaviour in class were also found in the most recent trial, a 16-week RCT of 450 UK children. 38 This needs to be explored in further studies, perhaps using higher doses of omega-3s, as the most recent trials have used fairly small amounts (i.e. 0.01-0.4g/day). more modest, although results may be hindered by the small number of studies, the limited duration, low intakes of omega-3s and a lack of consensus about the optimal balance between EPA and DHA. Studies in children with behavioural disorders report more consistent benefits for omega-3s, but these findings cannot be extrapolated to healthy populations. More controlled trials in a range of age groups are needed to determine optimal intakes of omega-3s during childhood. Until then, the recommended intake of 0.45g omega-3s per day remains relevant, although it is unlikely that most UK children will be able to achieve this level of omega-3s given the present low consumption of oily fish. Efforts to encourage children to eat more fish should continue as regular fish consumption offers nutritional value beyond omega-3s. Alongside this, fish oil supplements have an important role in bridging the gap between intakes and requirements. Numerous studies have found that levels of DHA in red blood cell phospholipids rise following supplementation with fish oil. Maternal supplementation also has the effect of boosting levels of DHA and EPA in breast milk and foetal blood. The beneficial impact of supplementation on omega-3s status has been seen consistently across many age groups. Supplements are particularly useful for children who cannot eat fish due to allergies, dislike or vegetarianism. This needs to be recognised to a greater extent in public health messages and dietary advice from health professionals.
References: 1. Ruxton CHS, et al (2005). The impact of long chain n-3 polyunsaturated fatty acids on human health. Nutrition Research Reviews; 18: 113-129. 2. Scientific Advisory Committee on Nutrition (SACN) & Committee on Toxicity (COT) (2004) Advice on fish consumption, benefits and risks. HM Stationery Office: London. 3. Food and Nutrition Board (FNB) of the Institute of Medicine of the National Academies (2002). Dietary fats, total fat and fatty acids. In Dietary Reference Intakes for energy, carbohydrates, fiber, fats, fatty acids, cholesterol, protein and amino acids (Macronutrients), 422541. 4. National Health and Medical Research Council (2005). Nutrient reference values for Australia and New Zealand including recommended dietary intakes. www.nhmrc.gov.au/publications/ synopses/_files/n35.pdf 5. World Health Organisation (WHO) (2008). Interim summary of conclusions and dietary recommendations on total fat and fatty acids. WHO, Geneva. 6. Gibbs RA, Rymer C, Givens DI (2010). Long-chain n-3 PUFA, intakes in the UK and the potential of a chicken meat prototype to increase them. Proceedings of the Nutrition Society; 69: 144-155. 7. Nelson M, et al (2007). Low Income Diet and Nutrition Survey. Volume 2, Food consumption and Nutrient Intake. The Stationery Office: London. 8. Bates B, Lennox A, Swan G (2010). National Diet and Nutrition Survey Headline results from year 1 of the rolling programme (2008-09). FSA and the DH, London. 9. Noble S, Emmett P (2001). Food and nutrient intake in a cohort of 8-month-old infants in the south-west of England in 1993. European Journal of Clinical Nutrition; 55: 698-707. 10. Emmett P, et al. (2002). Food and nutrient intakes of a population sample of 3-year-old children in the south west of England in 1996. Public Health Nutrition; 5: 55-64. 11. Crawford MA, Casperd NM, Sinclair AJ (1976). The long chain metabolites of linoleic avid linolenic acids in liver and brain in herbivores and carnivores. Comparative Biochemistry and Physiology; 54: 395401. 12. Clandinin MT, Chappell JE, Heim T (1982). Do low-weight infants require nutrition with chain elongation - desaturation products of essential fatty acids. Progress in Lipid Research; 21: 901-904. 13. Stinson AM, Wiegand RD, Anderson RE (1991). Fatty acid and molecular species compositions of phospholipids and diacylglycerols from rat retinal membranes. Experimental Eye Research; 52: 213-218. 14. Giusto NM, et al (2000). Lipid metabolism in vertebrate retinal rod outer segments. Progress in Lipid Research; 39: 315-391. 15. OConnor DL, Hall R, Adamkin D (2001). Growth and development in preterm infants fed long-chain polyunsaturated fatty acids: a prospective, randomized controlled trial. Pediatrics; 108: 359-371. 16. Innis SM, Friesen RW (2008). Essential n-3 fatty acids in pregnant women and early visual acuity maturation in term infants. American Journal of Clinical Nutrition; 87: 548-57. 17. Dunstan J, et al (2003). Fish oil supplementation in pregnancy modifies neonatal allergen-specific immune responses and clinical outcomes in infants at high risk of atopy: a randomised controlled trial. Journal of Allergy and Clinical Immunology; 112: 1178-84. 18. Dunstan JA, et al (2003). Maternal fish oil supplementation in pregnancy reduces interleukin-13 levels in cord blood of infants at high risk of atopy. Clinical and Experimental Allergy; 33: 442-448. 19. Furuhjelm C, et al (2009). Fish oil supplementation in pregnancy and lactation may decrease the risk of infant allergy. Acta Paediatrica; 98: 1461-7. 20. Helland IB Smith L, et al. (2003). Maternal supplementation with very-longchain n-3 fatty acids during pregnancy and lactation augments children's IQ at 4 years of age. Pediatrics; 111: e39-44. 21. Judge MP, Harel O, Lammi-Keefe CJ (2007). Maternal consumption of a docosahexaenoic acid-containing functional food during pregnancy, benefit for infant performance on problem-solving but not on recognition memory tasks at age 9 mo. American Journal of Clinical Nutrition; 85: 1572-7. 22. Dunstan JA, et al. (2008). Cognitive assessment of children at age 2(1/2) years after maternal fish oil supplementation in pregnancy, a randomised controlled trial. Archives of Disease in Childhood Fetal Neonatal Edition; 93: F45-50. 23. Judge MP, Harel O, Lammi-Keefe CJ (2007). A docosahexaenoic acid-functional food during pregnancy benefits infant visual acuity at four but not six months of age. Lipids; 42: 117-22. 24. Malcolm CA, et al (2003). Scotopic electroretinogram in term infants born of mothers supplemented with docosahexaenoic acid during pregnancy. Investigative Ophthalmology and Visual Science; 44: 3685-91. 25. Malcolm CA, et al (2003). Maternal docosahexaenoic acid supplementation during pregnancy and visual evoked potential development in term infants, a double blind, prospective, randomised trial. Archives of Disease in Childhood Fetal Neonatal Edition; 88: F383-90. 26. Auestad NR, et al (2009). Growth and development in term infants fed long-chain polyunsaturated fatty acids, a doublemasked, randomized, parallel, prospective, multivariate study. Pediatrics; 108: 372-81. 27. Birch EE, et al (2000). A randomized controlled trial of early dietary supply of longchain polyunsaturated fatty acids and mental development in term infants. Developmental Medicine and Child Neurology; 42: 174-181. 28. Birch EE, et al (2005). Visual maturation of term infants fed long-chain polyunsaturated fatty acidsupplemented or control formula for 12 mo. American Journal of Clinical Nutrition; 81: 871-9. 29. Hoffman DR, et al (2000). Impact of early dietary intake and blood lipid composition of long-chain polyunsaturated fatty acids on later visual development. Journal of Pediatric Gastroenterology and Nutrition; 31: 540-53. 30. Birch EE, et al (2007). Visual acuity and cognitive outcomes at 4 years of age in a double-blind, randomized trial of long-chain polyunsaturated fatty acid-supplemented infant formula. Early Human Development; 83: 279-84. 31. Uauy R, et al (2003). Term infant studies of DHA and ARA supplementation on neurodevelopment, results of randomized controlled trials. Journal of Pediatrics; 143(4 Suppl): S17-25. 32. Ells L, Hillier FC, Summerbell CD (2006). A systematic review of the effect of nutrition, diet and dietary change on learning, education and performance of children of relevance to UK schools. Food Standards Agency Project Code: N05070. www.food.gov.uk/multimedia/pdfs/system review.pdf 33. Theinparsert A, et al (2002). Attendance and school performance in Thai school children, a randomised double-blind controlled trial of docosahexaenic acid (DHA) and eicosapentaneoic acid (EPA) 5th Congress of the International Society for the Study of Fatty Acids and Lipids (ISSFAL) Montreal 7-11 May. 34. Itomura M, et al (2005). The effect of fish oil on physical aggression in schoolchildrena randomized, double-blind, placebo-controlled trial. Journal of Nutrition and Biochemistry; 16: 163-171. 35. Osendarp S, et al (2007). Effect of a 12-mo micronutrient intervention on learning and memory in well-nourished and marginally nourished school-aged children, 2 parallel, randomized, placebo-controlled studies in Australia and Indonesia. American Journal of Clinical Nutrition; 86: 10821093. 36. Mazurak VC, et al (2008). Long-chain polyunsaturated fat supplementation in children with low docosahexaenoic acid intakes alters immune phenotypes compared with placebo. Journal of Pediatric Gastroenterology and Nutrition; 46: 570-9. 37. Ryan AS, Nelson EB (2008). Assessing the effect of docosahexaenoic acid on cognitive functions in healthy, preschool children, A randomized, placebocontrolled, double-blind study. Clinical Pediatrics; 47: 355362. 38. Kirby A, et al (2010). A double-blind, placebo-controlled study investigating the effects of omega-3 supplementation in children aged 8-10 years from a mainstream school population. Research in Developmental Disabilities; 31: 718-30.

Discussion
The evidence reviewed here suggests that omega-3s are vital in utero, and in the first few years of life. Maternal supplementation of omega-3s, and supplementation of infants, boosts DHA/EPA status, as well as supporting the normal development of the brain, eye and immune system. In healthy, school-aged children, the benefits of supplementation are

Table Three: RCT in Normal, Healthy Children

Reference No. 33 34 Sample Details N=64, 8-12y N=166, 10y Intervention Fish oil (1.3g/d) vs. placebo as fortified foods for 6 months Fish oil (3.68g/d) vs. placebo as fortified foods for 3 months Multinutrient capsule (containing 0.09g DHA + 0.02g EPA/d) vs. placebo for 12 months DHA/AA vs. placebo for 7 months. DHA = 0.01-0.02g/d 0.4g/day DHA vs. placebo for 4 months Significant Findings No differences in school performance No differences in performance. Aggression lower in girls taking fish oil Improved DHA/EPA status, verbal learning and memory in intervention group More normal immune function in DHA/AA group No differences in cognitive function. Improved performance in listening comprehension and vocabulary acquisition tests in group with better DHA status No differences in IQ or school performance. Decreased inattention and improved behaviour in active group

35

N=396, 6-10y

36 37

N=37 children with low DHA intakes N=175; 4y

38

N=450, 8-10y

DHA/EPA (0.23g/day) vs. olive oil placebo, RCT for 4 months then all children received active intervention for 8 weeks

Key: RCT: randomised controlled trial; DHA: docosahexaenoic acid; EPA: eicosapentaenoic acid; AA: arachidonic acid; d: day; y: years; N: sample size; IQ: intelligence quotient.

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