ORIGINAL

ARTICLES
Improved Neurodevelopmental Outcomes Associated with
Bovine Milk Fat Globule Membrane and Lactoferrin in Infant
Formula: A Randomized, Controlled Trial
Fei Li, MD, PhD1, Steven S. Wu, MD2, Carol Lynn Berseth, MD2,3, Cheryl L. Harris, MS2, James D. Richards, PhD4,5,
Jennifer L. Wampler, PhD2, Weihong Zhuang, MS2, Geoffrey Cleghorn, MD2,6, Colin D. Rudolph, MD, PhD2,7,
Bryan Liu, MD, PhD2,8, D. Jill Shaddy, MA9, and John Colombo, PhD9

Objective To evaluate neurodevelopment, growth, and health outcomes in infants receiving bovine milk fat
globule membrane (MFGM) and lactoferrin in infant formula.
Study design Healthy term infants were randomized to a cow’s milk-based infant formula or MFGM + LF (a similar
infant formula, with an added source of bovine milk fat globule membrane [bMFGM; whey protein-lipid concentrate,
5 g/L] and bovine lactoferrin [0.6 g/L]) through 365 days of age. The Bayley Scales of Infant Development, 3rd edition
cognitive composite score at day 365 was the primary outcome. Secondary outcomes included tolerance mea-
sures through day 365, additional neurodevelopmental and language outcomes, growth, and medically confirmed
adverse events through day 545.
Results Of 451 infants enrolled (control, 228; MFGM + LF, 223), 291 completed study feeding and Bayley-III
testing at day 365 (control, 148; MFGM + LF, 143). The mean cognitive (+8.7), language (+12.3), and motor
(+12.6) scores were higher (P < .001) for the MFGM + LF group; no differences were observed at day 545. Global
development scores from day 120 to day 275 and attention at day 365 were significantly improved. Few group dif-
ferences in day 545 neurodevelopmental outcomes were detected, however scores of some subcategories of the
MacArthur-Bates Communicative Development Inventories were higher (P < .05) in the MFGM + LF group. The
overall incidence of respiratory-associated adverse events and diarrhea were significantly lower for the
MFGM + LF group through day 545.
Conclusions Infants receiving formula with added bovine MFGM and bovine lactoferrin had an accelerated neu-
rodevelopmental profile at day 365 and improved language subcategories at day 545. Formulas were associated
with age-appropriate growth and significantly fewer diarrhea and respiratory-associated adverse events through
545 days of age. (J Pediatr 2019;-:1-8).
Trial registration Clinicaltrials.gov: NCT02274883.

A
lthough the World Health Organization recommends exclusive breastfeeding through 6 months of age1 and human
milk is recognized as the gold standard for infant nutrition, a significant proportion of infants worldwide receive partial
or exclusive formula feeding. Over the past century, changes in infant
formula to better match the dynamic features of breast milk have brought the
composition, functionality, and health-based outcomes closer together for in-
fants receiving human milk or infant formula.2 For example, lactoferrin is a rela- 1
From the Departments of Developmental and
Behavioral Pediatrics & Child Primary Care, MOE-
tively well-studied bioactive component3,4 that shares approximately 70% Shanghai Key Lab for Children’s Environmental Health,
Xinhua Hospital Affiliated To Shanghai Jiaotong
sequence homology and comparable bioactivity with bovine lactoferrin (as re- University School of Medicine, Shanghai, China; Clinical 2
3,5
viewed ). We previously reported 0.6 g bovine lactoferrin per liter in routine Research, Department of Medical Affairs, Mead Johnson
3
Nutrition, Evansville, IN; Medical and Scientific Affairs,
infant formula was safe, well-tolerated, and associated with normal growth in Brightseed, San Francisco, California; Nutrition 4

Science, Department of Medical Affairs, Mead Johnson

healthy term infants through 365 days of age6; dietary bovine lactoferrin was 5
Nutrition, Evansville, IN; DSM Nutritional Products,
also demonstrated to decrease invasive fungal infections in preterm infants7
6
Parsippany, New Jersey; Faculty of Health, Queensland
University of Technology, Brisbane, Australia;
8 9
and to decrease parasite colonization and vomiting and diarrhea in older 7
Department of Pediatrics, University of California, San
8
Francisco, CA; College of Biotechnology, East China
children. University of Science and Technology, Shanghai, China;
9
Schiefelbusch Institute for Life Span Studies, University
of Kansas, Lawrence, KS
Funded by Mead Johnson Nutrition (Evansville, IN).
Shanghai Jiaotong University School of Medicine was
provided funding to implement neurodevelopmental
AE Adverse event testing and study site coordination. J.C. and D.S.
received travel funds to provide training in neurodeve-
ASQ Ages & Stages Questionnaire lopmental testing. S.W., J.W., G.C., C.H., and W.Z. are
Bayley-III Bayley Scales of Infant Development, 3rd edition employees of Mead Johnson Nutrition. C.B., J.R., C.R.,
CDI Communicative Development Inventories and B.L. were previously employed at Mead Johnson
Nutrition.
MFGM Milk fat globule membrane
bMFGM Bovine MFGM 0022-3476/$ - see front matter. ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jpeds.2019.08.030

1
THE JOURNAL OF PEDIATRICS  www.jpeds.com Volume -  - 2019

Milk fat globule membrane (MFGM), is a complex

protein–phospholipid trilayer that surrounds fat droplets Table II. Nutrient composition per 100 kcal (20
secreted into milk.10-13 It is highly conserved across mamma- Calories/fl oz)*
lian species. Emergent research supports MFGM as a bioac- Study formula (target values)
tive component for digestive health, immune, and central Stage 1 Stage 2
nervous system development and function (as reviewed14). Nutrients Control MFGM + LF Control MFGM + LF
Improved bovine fat globule separation during dairy process- †
Total protein, g 2.1 2.1 3.3 3.3
ing has facilitated bovine MFGM (bMFGM) incorporation in Total fat, g‡ 5.3 5.3 4.1 4.1
infant formula to better approximate the composition of Linoleic, mg 810 810 640 640
complex human milk lipids.3,15 Early clinical studies demon- a-Linolenic acid, mg 71 71 56 56
ARA, mg 25 25 25 25
strated the safety and potential developmental and behavioral DHA, mg 17 17 17 17
benefits of different sources of bMFGM or its components in Total carbohydrate, g§ 11.2 11.2 12.8 12.8
infant formula.16-22 Vitamin A, IU 280 280 300 300
Vitamin D, IU 62 62 56 56
Additional clinical data based on recognized study outcomes Vitamin E, IU 1.9 1.9 1.7 1.7
and consistent bMFGM sources would help establish recom- Vitamin K, mg 7.2 7.2 8 8
mendations for the addition of bMFGM to infant formula. Thiamin, mg 85 85 80 80
Riboflavin, mg 170 170 200 200
This randomized clinical trial was designed to evaluate neuro- Vitamin B6, mg 60 60 70 70
developmental outcomes in healthy term infants through Vitamin B12, mg 0.31 0.31 0.5 0.5
545 days of age (18 months) who received bMFGM and bovine Niacin, mg 660 660 700 700
Folic acid, mg 18 18 16 16
lactoferrin in infant formula through 365 days of age. Pantothenic acid, mg 570 570 650 650
Biotin, mg 2.7 2.7 3 3
Vitamin C, mg 18 18 20 20
Methods Choline, mg 24 24 24 24
Inositol, mg 8.5 8.5 7 7
Eligible infants were enrolled in this multicenter, double- Carnitine, mg{ 2 2 – –
Taurine, mg 6 6 4.3 4.3
blind, randomized, controlled, parallel group trial from Calcium, mg 79 79 110 110
November 2014 to October 2015 at 3 clinical sites in Fuyang, Phosphorus, mg 48 48 65 65
Anhui Province, China (ClinicalTrials.gov: NCT02274883). Magnesium, mg 8 8 9.5 9.5
Iron, mg 1.0 1.0 1.25 1.25
The research protocol and informed consent forms observing Zinc, mg 0.8 0.8 0.76 0.76
the Declaration of Helsinki (including October 1996 amend- Manganese, mg 18 18 17.8 17.8
ment) were approved by the Shanghai Nutrition Academy Copper, mg 65 65 68 68
Iodine, mg 17 17 22 22
Medical Ethical Committee. The study complied with good Selenium, mg 2.7 2.7 2.5 2.5
clinical practices. Parents or guardians provided written Sodium, mg 28 28 46 46
informed consent before enrollment. Mothers who had Potassium, mg 110 110 150 150
Chloride, mg 65 65 94 94
decided to exclusively provide infant formula were screened Total nucleotides, mg 3.1 3.1 4 4
for study eligibility. Participants were born at 37-42 weeks
of gestation and had received infant formula feeding for ARA, Arachidonic acid; DHA, docosahexaenoic acid.
*Study formulas were provided as powders and could not be differentiated by smell, consis-
³3 days before randomization. Infants were 10-14 days of tency, or any other characteristics; identical mixing instructions were provided (final product,
age at randomization. Other inclusion and exclusion criteria 20 calories/fluid ounce).
†Sources of protein for control: skim milk and whey protein concentrate (WPC); and for
are described in Table I (available at www.jpeds.com). Study MFGM + LF: skim milk, WPC, whey protein-lipid concentrate (5 g/L, source of bMFGM; Lacpro-
visits corresponded to 14 (
4 days; enrollment), 30 (3), 42 dan MFGM-10, Arla Foods Ingredients) and bovine lactoferrin (0.6 g/L; Friesland Campina
DMV).
(3), 60 (3), 90 (3), 120 (+5), 180 (7), 275 (+10), 365 ‡Sources of fat: base blend of palm olein, soybean, coconut, and high oleic sunflower oils;
(+10), and 545 (7) days of age. All developmental testing fungal-derived single cell oil (source of ARA); algal-derived single cell oil (source of DHA).
§Sources of carbohydrate: lactose (stage 1, 10.6 g; stage 2, 12.1 g) and prebiotic oligosaccha-
was performed by study site professionals proficient in the rides (stage 1, 0.62 g; stage 2, 0.7 g; source: blend of polydextrose [PDX, Litesse Two Polydex-
administration of cognitive tests. Participants were eligible trose; Danisco] and galacto-oligosaccharides [GOS; DOMO Vivinal GOS; FrieslandCampina
DMV] [1:1 ratio]).
to continue in the study and complete neurodevelopmental {Not added to stage 2 study formulas.
testing at days 365 and 545 even if study formula
consumption was discontinued after 180 days of age.
DMV, Amersfoort, the Netherlands). The amount and
Randomization and Study Group Allocation source of bMFGM was based on a prior infant formula
Participants were randomly assigned to receive one of two study,19 with the aim of adding sphingomyelin at a
staged, routine cow’s milk-based study formulas (Mead John- concentration within the reported human milk range.23,24
son Nutrition, Evansville, Indiana; Table II): a control formula Participants received exclusive study formula feeding
or MFGM + LF, a similar formula with added whey protein- through day 120. Within each study group, stage 1 formula
lipid concentrate (5 g/L, source of bMFGM; Lacprodan was used up to day 180 and switched to a corresponding
MFGM-10, Arla Foods Ingredients, Basking Ridge, New stage 2 formula through day 365. The study sponsor created
Jersey) and bovine lactoferrin (0.6 g/L; FrieslandCampina a computer-generated, sex-stratified randomization schedule

2 Li et al
- 2019 ORIGINAL ARTICLES

provided in sealed consecutively numbered envelopes for each Statistical Analyses

study site. Study formula was assigned by opening the next A sample size of 143 infants per group was required to detect
sequential envelope from the appropriate set at the study site. a 5-point difference in the Bayley-III cognitive composite
Study formulas, each designated by 2 unique codes known score (SD, 15; 80% power; a = 0.05; 2 tailed test). We aimed
only to the sponsor, were dispensed to parents at each visit to enroll approximately 450 participants to accommodate a
before day 365. Neither product labels nor sealed envelopes potential attrition rate of 35%. Bayley-III composite scores
allowed direct unblinding by the study site. Blinding could were analyzed separately by ANOVA and post hoc by AN-
be broken by study sponsor personnel in the event of a COVA to adjust for potential confounding variables. With
medical emergency. In this study, it was not necessary to the exception of a one-tailed test for comparison of mean
break the study code prematurely. weight growth rates (per American Academy of Pediatrics
Task Force on Clinical Testing of Infant Formulas30),
all other secondary outcome comparisons were 2 tailed
Bayley Scales of Infant Development, 3rd edition (a = 0.05). Detailed statistical analysis methods for other sec-
Testing ondary outcomes are provided in the Appendix. All analyses
The Bayley Scales of Infant Development, 3rd edition (Bayley- were conducted using SAS version 9.4 (SAS Institute, Cary,
III; developed and validated in a US population25) evaluates North Carolina).
infants and children from 1 to 42 months of age. The cogni-
tive, language (receptive and expressive communication),
and motor (fine and gross motor) domains were assessed by Results
a trained evaluator. The social-emotional and adaptive
behavior scales were assessed by parent questionnaire. Com- A total of 451 participants were randomized and received
posite scores (cognitive, language, and motor) were converted allocated study formula (control, n = 228; MFGM + LF,
from raw scores based on successful completion of items at n = 223) (Figure 1; available at www.jpeds.com). No group
age of testing (standardized mean, 100; range varies by scale: differences were observed in birth characteristics, body
cognitive and social-emotional, 55-145; language, 47-153; weight, length, or head circumference by sex or other
motor, 46-154; and adaptive behavior, 40-160). The mean family demographics collected at study enrollment
scores may vary based on country, age, or developmental (Table III). For all participants, no statistically significant
domain (compared with US data), and normative data are group differences were detected for study formula
not available for all populations or languages of interest.26 discontinuation before day 365 (P = .96). No group
The Bayley-III has been previously translated into Chinese differences in participant characteristics or family
(Mandarin), adapted for the Chinese population,27 and demographics were detected for those who discontinued
used as a developmental assessment tool in two further clin- the study. The most common reason for study
ical studies.28,29 The Bayley-III (Chinese version) was discontinuation was that the participant was lost to follow-
completed at days 365 and 545. The primary outcome was up. A total of 292 infants completed study feeding through
the Bayley-III cognitive composite score at day 365. day 365 (control, n = 148; MFGM + LF, n = 144).

Global Developmental Status: Bayley-III Primary

Other Secondary Outcomes and Secondary Outcomes
Weight growth rate from 14 to 120 days of age was a key sec- Primary outcome Bayley-III data were available for all who
ondary growth and safety outcome. At study enrollment, in- completed study feeding with the exception of one partici-
fant birth characteristics and family demographics data were pant in the MFGM + LF group (Figure 1). The Bayley-III
collected; parents completed a baseline recall of tolerance and cognitive composite mean  SE score at day 365 was
stool characteristics. At all subsequent study visits through significantly higher for the MFGM + LF vs the control
day 365, a 24-hour recall of formula intake, tolerance, and group (111.0  0.9 vs 102.3  0.9; an 8.7-point difference;
stool characteristics was collected. Anthropometric measures P < .001) (Table IV). MFGM + LF vs control language
were recorded at all study visits. Medically confirmed adverse (122.6  0.9 vs 110.3  0.9; a 12.3-point difference) and
events (AEs) were collected through day 545 and coded ac- motor (118.3  1.2 vs 105.7  1.2; a 12.6-point difference)
cording to specific AE and body system involved. In addition mean scores were also significantly higher (P < .001). No
to the Bayley-III, the following instruments used were significant group differences were detected in social-
previously translated, revised, and adapted for use in emotional or general adaptive mean scores. Similar results
Chinese populations: Ages & Stages Questionnaire (ASQ), persisted when adjusted for family income, parental
MacArthur-Bates Communicative Development Inventories education, and other socioenvironmental variables. Owing
(CDI), and Carey Toddler Temperament Scales (TTS). The to study attrition after day 365 nearly 40% of participants
ASQ was completed at days 120, 180, and 275. The CDI, did not undergo subsequent testing; no group differences
TTS, and Single Object Free Play Task were conducted at were detected (adjusted or unadjusted) in any Bayley-III
days 365 and 545. All secondary outcomes are detailed in domain in participants tested at day 545 (control, n = 88;
the Appendix (available at www.jpeds.com). MFGM + LF, n = 95).
Improved Neurodevelopmental Outcomes Associated with Bovine Milk Fat Globule Membrane and Lactoferrin in Infant 3
Formula: A Randomized, Controlled Trial
THE JOURNAL OF PEDIATRICS  www.jpeds.com Volume -

differences were detected at day 365; significantly higher

Table III. Birth characteristics* and infant and family scores were detected for the MFGM + LF vs control group
demographics at enrollment at day 545 in sentence complexity (using words in longer
Characteristics Control MFGM + LF and more grammatically correct combinations) and 2
Total no. of participants 228 223 categorical items: absent owners (naming an absent person
Birth characteristics to whom a visible object belongs) and Chinese classifiers
Weight, g 3390.5  23.2 3438.2  23.4
Length, cm 49.8  0.1 50.0  0.1
(grammatical marker specific to Chinese language). For
No. of males/females 134/94 131/92 TTS scores, a statistically significant group difference in 1
Anthropometrics at enrollment of 9 domains (activity level) was detected at day 365
Males
Weight, g 3827.3  34.2 3853.8  34.6
(Table IX; available at www.jpeds.com). No group
Length, cm 52.0  0.1 52.1  0.1 differences were detected at day 545. Using the Single
Weight-for-length z-score 0.1  0.1 0.1  0.1 Object Free Play Task to measure attention, look duration
Head circumference, cm 35.5  0.1 35.6  0.1
Females
(mean  SE) at day 365 was significantly longer in the
Weight, g 3708.1  44.9 3750.7  45.5 MFGM + LF vs the control group (23.9  2.0 vs
Length, cm 51.5  0.1 51.5  0.1 18.2  2.0 seconds; P = .03) (Table X; available at www.
Weight-for-length z-score 0.0  0.1 0.2  0.1
Head circumference, cm 35.0  0.1 35.2  0.1
jpeds.com). No group differences were detected at day 545
No. family members in household 4.5  0.1 4.4  0.1 (MFGM + LF, n = 29: 21.0  2.4 seconds vs control,
Maternal age at birth, y n = 27: 23.0  2.5 seconds); however, data availability was
<25 72 (32) 62 (28)
25-29 102 (45) 108 (48)
low owing to limitations on data usability and study
30-35 47 (21) 43 (19) attrition. Groups were similar for look episodes at days 365
>35 7 (3) 10 (4) and 545.
Maternal use of DHA supplements
Regular consumption 67 (29) 71 (32)
(³1 time/week) Infant Growth
Did not consume regularly 161 (71) 152 (68) No statistically significant group differences by sex in weight
Maternal use of prenatal vitamins
Regular consumption 69 (30) 73 (33)
growth rate from days 14 to 120 were detected (Table XI;
(³1 time/week) available at www.jpeds.com). As outlined in American
Did not consume regularly 159 (70) 150 (67) Academy of Pediatrics guidance, rate of weight gain is the
Monthly average
family income, RMB
most important consideration in clinical evaluation of
<3000 61 (27) 67 (30) infant formula with differences of >3 g/day over a 3- to
3000-5999 119 (52) 120 (54) 4-month period considered clinically significant.30 No
6000-8000 33 (14) 22 (10)
>8000 15 (17) 14 (6)
statistically significant group differences by sex were
Maternal education observed for weight, length, or head circumference growth
No formal education 2 (1) 3 (1) rates for any measured age range, with the exception of
Primary school 12 (5) 14 (6)
Junior school 135 (59) 140 (63)
small differences in length growth rate (0.01 cm/day) for
High school/technical school 56 (25) 40 (18) females from day 14 to 60 or day 14 to 90. No
Associate degree 18 (8) 20 (9) statistically significant group differences by sex were
Bachelor degree 4 (2) 6 (3)
Masters (or above) degree 1 (0) 0 (0)
observed for mean achieved weight or weight-for-length
Paternal education z-score at any measured time point up to 545 days of age;
No formal education 1 (0) 1 (0) statistically significant, minor differences in achieved
Primary school 19 (8) 17 (8)
Junior school 116 (51) 119 (53)
length and head circumference are reported in Table XII
High school/technical school 66 (29) 53 (24) (available at www.jpeds.com). The mean achieved weight
Associate degree 18 (8) 24 (11) for males and females using the World Health
Bachelor degree 7 (3) 9 (4)
Masters (or above) degree 1 (0) 0 (0)
Organization weight-for-age standard growth chart31
plotted between the 75th and 90th percentiles throughout
RMB, renminbi. the study period (Figure 2 and Figure 3; available at
Values are number (%) or mean  SE.
*All participants identified as Asian. www.jpeds.com).

Other Secondary Outcomes through 18 Months of Tolerance and AEs

Age The mean study formula intake (mL/day) increased from day
ASQ scores (mean  SE) were significantly higher in 30 (approximately 800 mL/day) to 120 (approximately
the MFGM + LF vs control group at day 120 (Table V; 930 mL/day) for both groups by sex, indicating typical intake
available at www.jpeds.com). Higher scores for all 5 for both groups. Group intake was similar at all time points
domains in the MFGM + LF group persisted from day 120 assessed (data not shown); intake began to plateau by day 120
to day 275 and a significant overall effect was detected to 180 and decreased slightly by day 275 (approximately
(Table VI; available at www.jpeds.com). CDI scores were 900 mL/day) as parents and caregivers begin to offer comple-
used as a measure of language development (Table VII and mentary foods. Fussiness and amount of gas (with a minor
Table VIII; available at www.jpeds.com). No group exception at day 42) were similar at all study time points
4 Li et al
- 2019 ORIGINAL ARTICLES

Table IV. Bayley-III composite scores, days 365 and 545

Bayley-III composite score
Unadjusted Adjusted*
Control MFGM + LF Control MFGM + LF
Domains (n = 148) (n = 143) P value (n = 148) (n = 143) P value
Primary outcome
Day 365
Cognitive 102.3  0.9 111.0  0.9 <.001 102.1  1.0 110.8  1.0 <.001
Secondary outcomes
Language 110.3  0.9 122.6  0.9 <.001 109.8  1.0 122.1  1.0 <.001
Motor 105.7  1.2 118.3  1.2 <.001 104.8  1.3 117.3  1.3 <.001
Social-emotional 97.1  1.1 97.2  1.1 .95 96.8  1.2 97.0  1.2 .91
General adaptive 103.3  1.2 105.1  1.3 .30 102.7  1.4 104.9  1.4 .21
Control MFGM + LF Control MFGM + LF
(n = 88) (n = 95) P value (n = 88) (n = 95) P value
Day 545
Cognitive 110.5  1.1 111.8  1.0 .39 111.1  1.2 112.1  1.1 .50
Language 116.9  0.8 117.0  0.7 .93 117.0  0.9 117.2  0.8 .83
Motor 131.8  1.0 132.5  1.0 .60 132.3  1.2 132.9  1.1 .70
Social-emotional 98.4  1.9 97.3  1.8 .67 97.9  2.1 97.0  2.0 .73
General adaptive 108.5  1.9 109.1  1.9 .83 108.7  2.2 109.1  2.1 .90

Values are mean  SE.

*ANCOVA model included the following adjustments for sex, birth weight, family income, number of family members living in the household, father education, mother education, mother’s age when
participant was born, maternal DHA supplement use during last 12 weeks of pregnancy, maternal prenatal vitamin use during last 12 weeks of pregnancy, and exposure to smoking at study enroll-
ment.

(Table XIII and Table XIV; available at www.jpeds.com). No Although the reported group difference was lower than
differences in mean stool frequency (number per day) or observed in the current study (approximately 4 vs 9 points),
stool consistency were detected at any time point assessed the feeding period was also shorter (6 vs 12 months) in the
(Table XV; available at www.jpeds.com). previous study. Although our study did not include a
The overall incidence of AEs categorized by respiratory breastfed comparison group, the magnitude of difference
and gastrointestinal system, including the specific incidences for the mean cognitive score between MFGM + LF and con-
of upper respiratory tract infections, cough, and diarrhea, trol groups was comparable with the previously reported
were significantly lower for the MFGM + LF group than comparison of formula-fed to breastfed infants.19
for the control group (Table XVI). Episodes of respiratory In addition, although the mean Bayley-III cognitive, lan-
and diarrhea events were also significantly lower. No group guage, and motor scores in this study were higher for both
difference in the incidence of constipation was detected. groups relative to US norms (100  15), the control group
No group differences in the skin system, including eczema, mean scores seemed to be relatively comparable with scores
were detected. No group difference was detected in the previously reported for neurotypical infants and toddlers in
number of participants for whom at least one medically 6 districts of Shanghai (n = 457) using the Chinese adapta-
confirmed AE was reported (control, 208, 91%; tion of the Bayley-III (cognitive, 104.62  11.40; language,
MFGM + LF, 198, 89%; P = .43). No serious AEs were 105.96  12.43; and motor, 106.27  13.39).27 Similar obser-
reported. vations of higher scores in ³1 Bayley-III subscales for popu-
lations worldwide compared with US reference data are well-
Discussion described,26,32,33 reinforcing the need for population-specific
norms.
The current randomized, double-blinded trial demonstrated Rapid acceleration in expressive language34,35 and
an accelerated neurodevelopmental profile by 12 months of increased attentional engagement36 from 12 to 18 months
age in infants receiving bioactive bMFGM components and of age is well-documented. In the current study, infants
bovine lactoferrin in infant formula at concentrations similar receiving bMFGM and bovine lactoferrin scored higher
to human milk. The mean Bayley-III cognitive scores at in selected communicative measures, including the Bayley-
12 months of age were higher by 8.7 points and language III language domain at 12 months of age. Both groups fol-
and motor scores by approximately 12 points for infants in lowed a pattern of longitudinal vocabulary growth over
the MFGM + LF group than those in the control group. Dif- 12-18 months of age. The observation that few group differ-
ferences persisted after adjustment for potentially confound- ences in neurodevelopmental outcomes were detected at
ing socioeconomic and environmental variables. These 18 months could indicate that the control group caught up
findings are in line with a prior study demonstrating signifi- developmentally and the earlier advantages observed in the
cantly higher mean Bayley-III cognitive scores for infants MFGM + LF group were not sustained. However, scores
receiving formula with added bMFGM (vs without).19 for 3 subcategories of the CDI were significantly higher in

Improved Neurodevelopmental Outcomes Associated with Bovine Milk Fat Globule Membrane and Lactoferrin in Infant 5
Formula: A Randomized, Controlled Trial
THE JOURNAL OF PEDIATRICS  www.jpeds.com Volume -

Table XVI. Medically confirmed Adverse Events classified by body system and event category
AE Incidence
Body System and Category Study Group n (%) P
Respiratory Control 193 (85) .02
MFGM + LF 168 (75)
Upper respiratory tract infection Control 177 (78) .02
MFGM + LF 151 (68)
Cough Control 92 (40) .02
MFGM + LF 66 (30)
Gastrointestinal Control 157 (69) .02
MFGM + LF 130 (58)
Diarrhea Control 156 (68) .003
MFGM + LF 121 (54)
Constipation Control 27 (12) .45
MFGM + LF 21 (9)
Metabolic and Nutrition
Lack of Appetite Control 36 (16) .35
MFGM + LF 28 (13)
Skin Control 31 (14) .31
MFGM + LF 23 (10)
Diaper Rash Control 18 (8) .58
MFGM + LF 14 (6)
Eczema Control 9 (4) .80
MFGM + LF 7 (3)
Viral Skin Rash Control 7 (3) .54
MFGM + LF 4 (2)
Number of Episodes, n (%)
AE Episodes Study Group None 1 2 3 4 5 P
Respiratory* Control 35 (15) 54 (24) 58 (25) 54 (24) 25 (11) 2 (1) <.001
MFGM + LF 55 (25) 66 (30) 62 (28) 32 (14) 8 (4) 0 (0)
Diarrhea Control 72 (32) 112 (49) 43 (19) 1 (0) 0 (0) 0 (0) .005
MFGM + LF 102 (46) 91 (41) 27 (12) 3 (1) 0 (0) 0 (0)

*Respiratory includes: episodes of URI and Cough

the MFGM + LF group at 18 months of age. One explanation analysis of AEs suggested a low but increased, incidence of
could include differences in mode of administration (eg, eczema.18 Subsequently, no group differences in reported
Bayley-III by direct observation vs parent-reported CDI) or eczema were detected in infants receiving bMFGM-enriched
in testing content that may be sensitive to different compo- formula (same source as current study but slightly higher con-
nents of development. Another potential explanation lies in centration [approximately 6 g/L vs 5 g/L]) through 6 months
the concept of “developmental cascades,” defined as cumula- of age.19 In the current study, bMFGM and bovine lactoferrin
tive change in one domain that influences distal outcomes in infant formula were not associated with increased risk of
over time or shifts in other domains.37 In a study of eczema or any other AEs within the skin system through
the nutrient docosahexaenoic acid and development of atten- 18 months of age. A decreased risk of diarrhea in infants
tion in infants and toddlers, for example, a transition of and young children9,39,40 and lower respiratory infection rates
neurodevelopmental effects from the first to second year in infants41 and children with recurrent respiratory infec-
of age was observed.36,38 Along the same lines, the tions42 receiving dietary bovine lactoferrin has been demon-
MFGM + LF group demonstrated accelerated neurodevelop- strated previously. Clinical evidence of lower incidence of
ment by 12 months characterized in part by significantly diarrhea21 and otitis media20 in infants receiving dietary
longer attentional engagement and higher selected Bayley- bMFGM are also consistent with preclinical data supporting
III scores. Whereas the differences in these outcome measures antipathogenic effects. Consequently, we hypothesize that
did not persist at 18 months, improvements in several aspects the decrease in AEs in the present trial may be attributable
of language at 18 months may be suggestive of a develop- to both nutritional components.
mental cascade. We note several limitations of the present study. One is
Addition of whey lipid-protein concentrate (5 g/L, source of that a breastfed reference group was not enrolled. Such a
bMFGM) and bovine lactoferrin (0.6 g/L) in routine infant reference group certainly helps to gauge the degree to which
formula was safe, well-tolerated, and associated with age- formula-fed infants approach optimal levels of outcome;
appropriate growth and fewer gastrointestinal and respiratory however, the confounding of variables inherent in the use
AEs through 18 months of age. Previously, in term infants ran- of a breastfeeding reference group does not allow for direct
domized to a formula enriched with the same source of comparison and would not directly bear on the demonstra-
bMFGM (vs a control) through 4 months of age, a post hoc tion of the relative efficacy of the formulas evaluated in this

6 Li et al
- 2019 ORIGINAL ARTICLES

study. Another potential limitation is the inability to distin- 3. Lonnerdal B. Infant formula and infant nutrition: bioactive proteins of
guish with certainty between individual effects of MFGM and human milk and implications for composition of infant formulas. Am
J Clin Nutr 2014;99:712S-7S.
lactoferrin, although we note that a growing body of clinical
4. Rai D, Adelman AS, Zhuang W, Rai GP, Boettcher J, Lonnerdal B. Lon-
evidence to date has demonstrated neurodevelopmental or gitudinal changes in lactoferrin concentrations in human milk: a global
behavioral effects of MFGM and its components, whereas systematic review. Crit Rev Food Sci Nutr 2014;54:1539-47.
clinical evidence for lactoferrin in these domains is absent. 5. Donovan SM. The role of lactoferrin in gastrointestinal and immune
Finally, data availability at 18 months was low owing to study development and function: a preclinical perspective. J Pediatr
2016;173(Suppl):S16-28.
attrition and limitations on data usability.
6. Johnston WH, Ashley C, Yeiser M, Harris CL, Stolz SI, Wampler JL, et al.
Overall, the addition of bMFGM and bovine lactoferrin Growth and tolerance of formula with lactoferrin in infants through one
in an infant formula was associated with a significantly year of age: double-blind, randomized, controlled trial. BMC Pediatr
accelerated neurodevelopmental profile, including higher 2015;15:173.
ASQ scores from 4 to 9 months of age, higher mean 7. Manzoni P, Stolfi I, Messner H, Cattani S, Laforgia N, Romeo MG,
et al. Bovine lactoferrin prevents invasive fungal infections in very
Bayley-III cognitive, language, and motor scores, and
low birth weight infants: a randomized controlled trial. Pediatrics
longer sustained attention at 12 months, and higher scores 2012;129:116-23.
for some language domains (CDI) at 18 months of age. 8. Ochoa TJ, Chea-Woo E, Campos M, Pecho I, Prada A, McMahon RJ,
The current study is also the first to demonstrate safety, et al. Impact of lactoferrin supplementation on growth and preva-
tolerance, and association with typical growth, and a lence of Giardia colonization in children. Clin Infect Dis 2008;46:
1881-3.
significantly lower incidence of gastrointestinal- and
9. Egashira M, Takayanagi T, Moriuchi M, Moriuchi H. Does daily intake
respiratory-associated AEs through 18 months of age in in- of bovine lactoferrin-containing products ameliorate rotaviral gastroen-
fants receiving bMFGM components and bovine lactofer- teritis? Acta Paediatr 2007;96:1242-4.
rin in infant formula at concentrations similar to human 10. Heid HW, Keenan TW. Intracellular origin and secretion of milk fat
milk. Therefore, dietary bMFGM and bovine lactoferrin globules. Eur J Cell Biol 2005;84:245-58.
11. Lopez C, Briard-Bion V, Menard O, Rousseau F, Pradel P, Besle JM.
together may not only provide a better approximation of
Phospholipid, sphingolipid, and fatty acid compositions of the milk
the bioactive composition of human milk, but also fat globule membrane are modified by diet. J Agric Food Chem
contribute to beneficial cognitive, gastrointestinal, and res- 2008;56:5226-36.
piratory health outcomes. As noted, the field of MFGM 12. Gallier S, Gragson D, Cabral C, Jimenez-Flores R, Everett DW.
research is rapidly emerging and the data in our study Composition and fatty acid distribution of bovine milk phospho-
lipids from processed milk products. J Agric Food Chem 2010;58:
add to this knowledge base. More data will certainly be
10503-11.
needed to evaluate neurodevelopmental outcomes in older 13. Lopez C, Menard O. Human milk fat globules: polar lipid composition
children to help establish how the nutritive effects of and in situ structural investigations revealing the heterogeneous distri-
MFGM may be manifested longitudinally using a develop- bution of proteins and the lateral segregation of sphingomyelin in the
mental systems approach. n biological membrane. Colloids Surf B Biointerfaces 2011;83:29-41.
14. Demmelmair H, Prell C, Timby N, Lonnerdal B. Benefits of lactoferrin,
osteopontin and milk fat globule membranes for infants. Nutrients
We thank the local study site investigators: Professor Qian Hong (An- 2017;9.
hui Medical University, Anhui, China), Dr Chunyan Wang (Fuyang 15. Delplanque B, Gibson R, Koletzko B, Lapillonne A, Strandvik B. Lipid
Maternal and Child Health Hospital, Anhui, China), and Dr Weirong quality in infant nutrition: current knowledge and future opportunities.
Hu (Fuyang Fifth People’s Hospital, Anhui, China), and staff and J Pediatr Gastroenterol Nutr 2015;61:8-17.
SPRIM China for their cooperation. We thank parents and infants 16. Gurnida DA, Rowan AM, Idjradinata P, Muchtadi D,
for participating in this study. We thank Dr Zihua Ao (Mead Johnson Sekarwana N. Association of complex lipids containing ganglio-
Nutrition) for technical expertise. sides with cognitive development of 6-month-old infants. Early
Hum Dev 2012;88:595-601.
Submitted for publication Mar 15, 2019; last revision received Aug 2, 2019; 17. Tanaka K, Hosozawa M, Kudo N, Yoshikawa N, Hisata K, Shoji H,
accepted Aug 14, 2019. et al. The pilot study: sphingomyelin-fortified milk has a positive asso-
Reprint requests: Steven S. Wu, MD, Department of Clinical Research, ciation with the neurobehavioural development of very low birth
Medical Affairs, Mead Johnson Nutrition, 2400 W Lloyd Expy, Evansville, IN weight infants during infancy, randomized control trial. Brain Dev
47721. E-mail: Steven.Wu2@rb.com 2013;35:45-52.
18. Billeaud C, Puccio G, Saliba E, Guillois B, Vaysse C, Pecquet S, et al.
Safety and tolerance evaluation of milk fat globule membrane-
Data Statement enriched infant formulas: a randomized controlled multicenter non-
inferiority trial in healthy term infants. Clin Med Insights Pediatr
Data sharing statement available at www.jpeds.com. 2014;8:51-60.
19. Timby N, Domellof E, Hernell O, Lonnerdal B, Domellof M. Neurode-
velopment, nutrition, and growth until 12 mo of age in infants fed a
References low-energy, low-protein formula supplemented with bovine milk fat
1. WHO. Report of the expert consultation of the optimal duration globule membranes: a randomized controlled trial. Am J Clin Nutr
of exclusive breastfeeding, Geneva, Switzerland, 28-30 March 2014;99:860-8.
2001. Geneva, Switzerland: World Health Organization (WHO); 20. Timby N, Hernell O, Vaarala O, Melin M, L€ onnerdal B, Domell€of M. In-
2001. fections in infants fed formula supplemented with bovine milk fat
2. Lonnerdal B, Hernell O. An opinion on “staging” of infant formula: a globule membranes. J Pediatr Gastroenterol Nutr 2015;60:384-9.
developmental perspective on infant feeding. J Pediatr Gastroenterol 21. Zavaleta N, Kvistgaard AS, Graverholt G, Respicio G, Guija H,
Nutr 2016;62:9-21. Valencia N, et al. Efficacy of an MFGM-enriched complementary food

Improved Neurodevelopmental Outcomes Associated with Bovine Milk Fat Globule Membrane and Lactoferrin in Infant 7
Formula: A Randomized, Controlled Trial
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in diarrhea, anemia, and micronutrient status in infants. J Pediatr Gas- weight-for-length, weight-for-height and body mass index-for-age:
troenterol Nutr 2011;53:561-8. methods and development. Geneva: World Health Organization;
22. Veereman-Wauters G, Staelens S, Rombaut R, Dewettinck K, 2006. p. 312.
Deboutte D, Brummer RJ, et al. Milk fat globule membrane (IN- 32. Steenis LJ, Verhoeven M, Hessen DJ, van Baar AL. Performance of Dutch
PULSE) enriched formula milk decreases febrile episodes and may children on the Bayley III: a comparison study of US and Dutch norms.
improve behavioral regulation in young children. Nutrition PLoS One 2015;10:e0132871.
2012;28:749-52. 33. Chinta S, Walker K, Halliday R, Loughran-Fowlds A, Badawi N. A com-
23. Cilla A, Diego Quintaes K, Barbera R, Alegria A. Phospholipids in hu- parison of the performance of healthy Australian 3-year-olds with the
man milk and infant formulas: benefits and needs for correct infant standardised norms of the Bayley Scales of Infant and Toddler Develop-
nutrition. Crit Rev Food Sci Nutr 2016;56:1880-92. ment (version-III). Arch Dis Child 2014;99:621-4.
24. Claumarchirant L, Cilla A, Matencio E, Sanchez-Siles LM, Castro- 34. Feldman HM, Dollaghan CA, Campbell TF, Kurs-Lasky M, Janosky JE,
Gomez P, Fontecha J, et al. Addition of milk fat globule membrane as Paradise JL. Measurement properties of the MacArthur communicative
an ingredient of infant formulas for resembling the polar lipids of human development inventories at ages one and two years. Child Dev 2000;71:
milk. Int Dairy J 2016;61:228-38. 310-22.
25. Albers CA, Grieve AJ. Test Review: Bayley, N. (2006). Bayley Scales of In- 35. Tardif T, Fletcher P, Liang W, Kaciroti N. Early vocabulary develop-
fant and Toddler Development– Third Edition. San Antonio, TX: Har- ment in Mandarin (Putonghua) and Cantonese. J Child Lang
court Assessment. J Psychoeduc Assess 2007;25:180-90. 2009;36:1115-44.
26. Gasparini C, Caravale B, Rea M, Coletti MF, Tonchei V, Bucci S, et al. 36. Colombo J, Kannass KN, Shaddy DJ, Kundurthi S, Maikranz JM,
Neurodevelopmental outcome of Italian preterm children at 1year of Anderson CJ, et al. Maternal DHA and the development of attention
corrected age by Bayley-III scales: an assessment using local norms. Early in infancy and toddlerhood. Child Dev 2004;75:1254-67.
Hum Dev 2017;113:1-6. 37. Masten AS, Cicchetti D. Developmental cascades. Dev Psychopathol
27. Xu S-s, Huang H, Zhang J-s, Bian X-y, Lv N, Lv Y-b, et al. Research on 2010;22:491-5.
the applicability of Bayley Scales of Infant and Toddler Development-to 38. Colombo J. Recent advances in infant cognition: implications for long-
assess the development of infants and toddlers in Shanghai. Zhongguo chain polyunsaturated fatty acid supplementation studies. Lipids
ertong baojian zazhi 2011;1:014. 2001;36:919-26.
28. Peng M, Gao K, Ding Y, Ou J, Calabrese JR, Wu R, et al. Effects of pre- 39. Ochoa TJ, Chea-Woo E, Baiocchi N, Pecho I, Campos M, Prada A,
natal exposure to atypical antipsychotics on postnatal development and et al. Randomized double-blind controlled trial of bovine
growth of infants: a case-controlled, prospective study. Psychopharma- lactoferrin for prevention of diarrhea in children. J Pediatr 2013;162:
cology (Berl) 2013;228:577-84. 349-56.
29. Wu M, Wu D, Wu W, Li H, Cao L, Xu J, et al. Relationship between 40. Chen K, Chai L, Li H, Zhang Y, Xie HM, Shang J, et al. Effect of bovine
iodine concentration in maternal colostrum and neurobehavioral lactoferrin from iron-fortified formulas on diarrhea and respiratory tract
development of infants in Shanghai, China. J Child Neurol 2016;31: infections of weaned infants in a randomized controlled trial. Nutrition
1108-13. 2016;32:222-7.
30. AAP, Finberg L, Bell EF, Cooke RJ, Fomon SJ, Kleinman RE, et al. Task 41. King JC Jr, Cummings GE, Guo N, Trivedi L, Readmond BX, Keane V,
Force on Clinical Testing of Infant Formulas, Committee on Nutrition, et al. A double-blind, placebo-controlled, pilot study of bovine lactofer-
American Academy of Pediatrics: clinical testing of infant formulas with rin supplementation in bottle-fed infants. J Pediatr Gastroenterol Nutr
respect to nutritional suitability for term infants. Washington, DC: US 2007;44:245-51.
Food and Drug Administration, Center for Food Safety and Applied 42. Zuccotti GV, Trabattoni D, Morelli M, Borgonovo S, Schneider L,
Nutrition; 1988. p. 1-16. Clerici M. Immune modulation by lactoferrin and curcumin in children
31. WHO. WHO Multicentre Growth Reference Study Group. WHO with recurrent respiratory infections. J Biol Regul Homeost Agents
Child Growth Standards: length/height-for-age, weight-for-age, 2009;23:119-23.

8 Li et al
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Participants randomized
n = 451

Allocation

Control MFGM + LF
(n = 228) (n = 223)

Received study formula (n = 228) Received study formula (n = 223)

Follow-up

Completed study feeding through day 365 Completed study feeding through day 365
(n = 148) (n = 144)

Reasons for discontinuation Reasons for discontinuation

• Parent choice: formula-related (n = 1) • Parent choice: formula-related (n = 0)
• Parent choice: not formula-related (n = 17) • Parent choice: not formula-related (n = 22)
• Lost to follow-up (n = 62) • Lost to follow-up (n = 57)

Analysis – Primary Outcome

Analyzed (n = 148) Analyzed (n = 143)

• No Bayley-III testing; did not attend
day 365 Visit (n = 1)

Figure 1. Study allocation.

Figure 2. Mean achieved weight for male participants with World Health Organization reference percentiles (2nd to 98th)
through 18 months (14-545 days) of age. Control, stars; MFGM + LF, circles.

Improved Neurodevelopmental Outcomes Associated with Bovine Milk Fat Globule Membrane and Lactoferrin in Infant 8.e1
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Figure 3. Mean achieved weight for female participants with World Health Organization reference percentiles (2nd to 98th)
through 18 months (14-545 days) of age. Control, stars; MFGM + LF, circles.

Table I. Participant inclusion and exclusion criteria

Inclusion criteria Exclusion criteria
10-14 days of age at randomization, inclusive (day of birth is History of underlying metabolic or chronic disease; congenital malformation; or any other
considered day 0) condition which, in the opinion of the investigator, is likely to interfere with: the ability of
Exclusively formula fed for at least 3 days before the infant to ingest food, the normal growth and development of the infant, or the
randomization evaluation of the infant
Singleton birth Evidence of feeding difficulties or formula intolerance, such as vomiting or poor intake, at
Gestational age of 37-42 weeks (36 weeks and 6 days is time of randomization (at investigator discretion)
considered 36 weeks gestational age) Weight at visit 1 is <95% of birth weight [(weight at visit 1 O birth weight)  100 < 95%]
Birth weight of 2500-4000 g Infant is immunocompromised (according to a doctor’s diagnosis of immunodeficiency
Signed informed consent obtained for infant’s participation in such as combined immunodeficiencies, DiGeorge syndrome, Wiskott-Aldrich
the study syndrome, severe congenital neutropenia and secondary immunodeficiencies linked to
Parent or guardian of infant agrees not to enroll infant in HIV infection, Down syndrome or others), and children with known head, brain disease,
another interventional clinical research study while or injury such as microcephaly or macrocephaly
participating in this study

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Table V. ASQ domain scores, days 120, 180, and 275

Day 120 Day 180 Day 275
Control MFGM + LF Control MFGM + LF Control MFGM + LF
Domains (n = 187) (n = 187) P value (n = 185) (n = 183) P value (n = 167) (n = 166) P value
Communication 49.0  0.5 51.3  0.5 .003 50.7  0.5 51.4  0.5 .353 51.4  0.6 52.4  0.6 .227
Gross motor 49.6  0.5 52.2  0.5 <.001 48.4  0.6 49.4  0.6 .255 46.1  0.8 47.0  0.8 .437
Fine motor 46.6  0.6 49.5  0.6 .002 52.0  0.6 52.9  0.6 .262 53.4  0.5 54.5  0.5 .099
Problem solving 49.6  0.6 52.0  0.6 .002 49.4  0.6 51.0  0.6 .060 51.8  0.6 52.6  0.6 .294
Personal/social 46.5  0.5 50.2  0.5 <.001 47.0  0.6 48.4  0.6 .124 50.0  0.6 50.8  0.7 .351

Values are mean  SE.

Table VI. ASQ domain scores from day 120 to 275, repeated measures analysis
Day 120 Day 180 Day 275
P value
Control MFGM + LF Control MFGM + LF Control MFGM + LF for age*study P value
Domains n = 187 n = 187 n = 185 n = 183 n = 167 n = 166 group interaction for study group
Communication 49.1  0.5 51.4  0.5 50.8  0.5 51.5  0.5 51.5  0.6 52.5  0.6 .238 .010
Gross motor 49.7  0.6 52.3  0.6 48.6  0.6 49.5  0.6 46.2  0.7 47.1  0.7 .299 .010
Fine motor 46.6  0.6 49.5  0.6 52.0  0.6 52.9  0.6 53.4  0.6 54.6  0.6 .130 .002
Problem solving 49.7  0.6 52.1  0.6 49.5  0.6 51.1  0.6 51.9  0.6 52.7  0.6 .408 .003
Personal/social 46.5  0.6 50.2  0.6 47.1  0.6 48.4  0.6 50.0  0.6 51.0  0.6 .032 <.001

Values are mean  SE.

Improved Neurodevelopmental Outcomes Associated with Bovine Milk Fat Globule Membrane and Lactoferrin in Infant 8.e3
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Table VII. CDI words and gestures, day 365 Table VIII. CDI words and sentences, day 545
Parent Control MFGM + LF Parent Control MFGM + LF
responses (n = 148) (n = 143) P value responses (n = 88) (n = 95) P value
First sign of understanding How children use words
Responds when Absent object
name is called (comprehension)
Yes 146 (99) 139 (97) .441 Not yet 8 (9) 11 (12) .629
No 2 (1) 4 (3) Sometimes 39 (44) 32 (34)
Responds to “no no” Often 41 (47) 52 (55)
Yes 130 (88) 130 (91) .450 Absent owner
No 18 (12) 13 (9) Not yet 22 (25) 11 (12) .032
Responds to “there is Sometimes 40 (45) 47 (49)
mommy/daddy” Often 26 (30) 37 (39)
Yes 144 (97) 138 (97) .746 Absent object
No 4 (3) 5 (3) (production)
Starting to talk Not yet 44 (50) 38 (40) .179
Point/make sound Sometimes 31 (35) 38 (40)
when want object Often 13 (15) 19 (20)
Never 3 (2) 4 (3) .803 Past
Sometimes 48 (32) 42 (29) Not yet 47 (53) 49 (52) .434
Often 97 (66) 97 (68) Sometimes 33 (38) 31 (33)
Say “want” or “take” Often 8 (9) 15 (16)
Never 48 (32) 45 (31) .453 Future
Sometimes 58 (39) 49 (34) Not yet 67 (76) 68 (72) .269
Often 42 (28) 49 (34) Sometimes 16 (18) 16 (17)
Imitation Often 5 (6) 11 (12)
Never 54 (36) 56 (39) .314 Sentences
Sometimes 65 (44) 68 (48) Combining verbs
Often 29 (20) 19 (13) Not yet 46 (52) 47 (49) .480
Labeling Sometimes 38 (43) 40 (42)
Never 92 (62) 74 (52) .119 Often 4 (5) 8 (8)
Sometimes 38 (26) 50 (35) Possessive
Often 18 (12) 19 (13) Not yet 39 (44) 32 (34) .149
Summary scores Sometimes 38 (43) 47 (49)
Early gestures 13.3  0.4 13.5  0.4 .822 Often 11 (13) 16 (17)
Later gestures 15.6  0.6 16.4  0.6 .353 Chinese classifiers
Total actions 28.9  0.8 30.0  0.9 .396 Not yet 63 (72) 57 (60) .035
and gestures Sometimes 23 (26) 29 (31)
Phrases understood 20.7  0.5 21.3  0.5 .363 Often 2 (2) 9 (9)
Words understood 202.3  7.7 201.5  7.9 .940 Past tense
Words produced 12.2  1.7 12.6  1.7 .872 Not yet 67 (76) 60 (63) .071
Sometimes 16 (18) 26 (27)
Values are number (%) or mean  SE. Often 5 (6) 9 (9)
Combining
Not yet 36 (41) 44 (46) .649
Sometimes 46 (52) 35 (37)
Often 6 (7) 16 (17)
Summary scores
Words produced 255.1  21.0 254.1  20.4 .973
[Sentence] complexity 20.1  1.7 24.9  1.6 .041

Values are number (%) or mean  SE.

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Table IX. TTS domain scores, days 365 and 545

Day 365 Day 545
Control MFGM + LF Control MFGM + LF
Domains (n = 148) (n = 143) P value (n = 88) (n = 95) P value
Activity level 3.6  0.04 3.7  0.04 .029 3.8  0.05 3.8  0.04 .540
Regularity 3.0  0.04 2.9  0.04 .130 3.0  0.06 3.0  0.06 .812
Approach/withdrawal 3.1  0.06 3.2  0.06 .851 3.2  0.06 3.2  0.06 .483
Adaptability 3.4  0.04 3.5  0.04 .145 3.4  0.05 3.4  0.05 .911
Intensity 3.8  0.05 3.9  0.05 .572 4.1  0.06 4.0  0.05 .266
Mood 3.2  0.04 3.2  0.04 .535 3.4  0.06 3.3  0.06 .510
Persistence 3.7  0.04 3.8  0.04 .376 3.6  0.06 3.6  0.06 .872
Distractibility 4.1  0.04 4.0  0.04 .530 3.9  0.05 3.9  0.05 .297
Sensory threshold 3.5  0.04 3.5  0.05 .494 3.4  0.05 3.4  0.05 .980

TTS, Carey Toddler Temperament Scale.

Values are number mean  SE.

Table X. Five-minute single object free play, days 365 and 545
Day 365 Day 545
Control MFGM + LF Control MFGM + LF
Characteristics (n = 86) (n = 84) P value (n = 27) (n = 29) P value
Look duration
Longest 62.7  4.5 68.4  4.4 .344 74.5  6.9 66.9  6.8 .363
Total 232.5  4.4 241.8  4.3 .118 246.6  5.1 242.0  5.1 .457
Mean 18.2  2.0 23.9  2.0 .033 23.0  2.5 21.0  2.4 .519
Look episodes 15.8  0.6 14.4  0.6 .780 13.3  1.1 14.5  1.1 .951

Values are mean  SE.

Improved Neurodevelopmental Outcomes Associated with Bovine Milk Fat Globule Membrane and Lactoferrin in Infant 8.e5
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Table XI. Weight, length, and HC growth rates from day 14 to 30, 42, 60, 90, and 120
Growth rate
Days Group (n) Weight, g/d Length, cm/d HC, cm/d
Male
30 Control (127) 50.5  1.7 0.15  0.006 0.08  0.003
MFGM + LF (129) 48.6  1.7 0.14  0.006 0.08  0.003
42 Control (123) 49.0  1.3 0.15  0.004 0.08  0.002
MFGM + LF (122) 47.8  1.3 0.14  0.004 0.08  0.002
60 Control (116) 45.3  0.9 0.14  0.003 0.07  0.002
MFGM + LF (118) 43.6  0.9 0.14  0.003 0.07  0.002
90 Control (115) 41.4  0.8 0.13  0.002 0.06  0.001
MFGM + LF (114) 40.1  0.8 0.13  0.002 0.06  0.001
120 Control (111) 37.1  0.6 0.11  0.002 0.05  0.001
MFGM + LF (111) 36.5  0.6 0.12  0.002 0.05  0.001
Female
30 Control (91) 38.1  1.6 0.12  0.006 0.07  0.004
MFGM + LF (89) 39.2  1.7 0.13  0.006 0.08  0.004
42 Control (88) 39.2  1.2 0.13  0.005 0.07  0.003
MFGM + LF (88) 40.1  1.2 0.14  0.005 0.08  0.003
60 Control (80) 37.8  1.0 0.12  0.003* 0.06  0.002
MFGM + LF (81) 39.0  1.0 0.13  0.003 0.07  0.002
90 Control (79) 34.4  0.8 0.11  0.002* 0.05  0.001
MFGM + LF (78) 35.9  0.8 0.12  0.002 0.06  0.001
120 Control (77) 31.6  0.7 0.10  0.002 0.05  0.001
MFGM + LF (76) 32.7  0.7 0.11  0.002 0.05  0.001

Values are mean  SE.

HC, Head circumference.
*Control vs MFGM + LF, P < .05.

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Table XII. Achieved weight, length, weight-for-length z-scores, and HC at days 30, 42, 60, 90, 120, 275, 365, and 545
Weight-for-length
Days Group (n) Weight, g Length, cm z-score HC, cm
Male
30 Control (127) 4787  45 54.8  0.2 0.7  0.1 37.1  0.1
MFGM + LF (129) 4783  45 54.8  0.2 0.7  0.1 37.2  0.1
42 Control (123) 5369  49 56.7  0.2 0.7  0.1 38.0  0.1
MFGM + LF (122) 5355  49 56.6  0.2 0.7  0.1 38.0  0.1
60 Control (116) 6048  48 59.0  0.2 0.7  0.1 39.0  0.1
MFGM + LF (117) 6004  48 58.9  0.2 0.6  0.1 39.0  0.1
90 Control (115) 7168  72 62.0  0.2 1.1  0.1 40.4  0.1
MFGM + LF (112) 7086  73 62.2  0.2 0.8  0.1 40.5  0.1
120 Control (108) 7941  78 64.7  0.2 1.1  0.1 41.7  0.1
MFGM + LF (109) 7897  78 64.8  0.2 1.0  0.1 41.7  0.1
180 Control (111) 8905  83 68.2  0.2 1.2  0.1 43.4  0.1
MFGM + LF (109) 8889  84 68.3  0.2 1.2  0.1 43.5  0.1
275 Control (103) 9824  94 72.5  0.2 1.1  0.1 45.1  0.1
MFGM + LF (99) 9988  97 72.5  0.2 1.2  0.1 45.3  0.1
365 Control (93) 10 568  101 76.2  0.2 1.0  0.1 46.3  0.1
MFGM + LF (85) 10 675  108 76.1  0.3 1.1  0.1 46.5  0.1
545 Control (53) 11 900  162 82.5  0.4 0.9  0.1 47.5  0.2
MFGM + LF (55) 12 157  164 83.0  0.4 1.1  0.1 47.9  0.2
Female
30 Control (91) 4433  52 53.8  0.2 0.4  0.1 36.3  0.1*
MFGM + LF (89) 4516  53 54.0  0.2 0.5  0.1 36.7  0.1
42 Control (88) 4943  57 55.4  0.2 0.6  0.1 37.2  0.1*
MFGM + LF (88) 5012  57 55.8  0.2 0.5  0.1 37.6  0.1
60 Control (80) 5577  65 57.3  0.2 0.8  0.1 38.0  0.1*
MFGM + LF (80) 5664  65 57.9  0.2 0.7  0.1 38.5  0.1
90 Control (78) 6465  78 60.2  0.2* 0.9  0.1 39.3  0.1*
MFGM + LF (77) 6607  79 60.9  0.2 0.9  0.1 39.7  0.1
120 Control (74) 7178  89 62.9  0.2 0.9  0.1 40.5  0.1
MFGM + LF (74) 7310  89 63.2  0.2 1.0  0.1 40.8  0.1
180 Control (74) 8155  100 65.9  0.2* 1.2  0.1 42.2  0.2*
MFGM + LF (74) 8365  100 66.8  0.2 1.2  0.1 42.7  0.2
275 Control (69) 9110  109 70.2  0.3* 1.1  0.1 43.9  0.2*
MFGM + LF (71) 9327  107 71.1  0.3 1.1  0.1 44.3  0.2
365 Control (55) 9908  127 74.2  0.3 1.0  0.1 45.1  0.2
MFGM + LF (60) 9939  122 74.9  0.3 0.9  0.1 45.3  0.2
545 Control (35) 11 049  173 80.7  0.4 0.8  0.1 45.9  0.2
MFGM + LF (40) 11 093  160 81.0  0.4 0.8  0.1 46.3  0.2

Values are mean  SE.

*Control vs MFGM + LF, P < .05.

Table XIII. Fussiness at days 14, 30, 42, 60, 90, 120, 180, and 365*
Days Group Not at all Slightly Moderately Very Extremely P value
14 Control 53 (23) 131 (57) 44 (19) 0 (0) 0 (0) .863
MFGM + LF 54 (24) 125 (56) 41 (18) 3 (1) 0 (0)
30 Control 27 (12) 147 (67) 41 (19) 3 (1) 0 (0) .886
MFGM + LF 30 (14) 143 (66) 43 (20) 2 (1) 0 (0)
42 Control 29 (14) 141 (67) 39 (19) 1 (0) 0 (0) .929
MFGM + LF 25 (12) 149 (71) 34 (16) 2 (1) 0 (0)
60 Control 36 (18) 128 (65) 30 (15) 2 (1) 0 (0) .186
MFGM + LF 26 (13) 136 (69) 30 (15) 5 (3) 0 (0)
90 Control 45 (23) 130 (67) 18 (9) 0 (0) 0 (0) .486
MFGM + LF 42 (22) 125 (66) 21 (11) 1 (1) 0 (0)
120 Control 59 (32) 116 (64) 7 (4) 0 (0) 0 (0) .969
MFGM + LF 63 (34) 112 (61) 7 (4) 1 (1) 0 (0)
180 Control 67 (36) 113 (61) 5 (3) 0 (0) 0 (0) .253
MFGM + LF 78 (43) 100 (55) 5 (3) 0 (0) 0 (0)
275 Control 90 (52) 80 (47) 2 (1) 0 (0) 0 (0) .934
MFGM + LF 91 (54) 75 (44) 4 (2) 0 (0) 0 (0)
365 Control 82 (55) 65 (44) 1 (1) 0 (0) 0 (0) .830
MFGM + LF 82 (57) 59 (41) 2 (1) 0 (0) 0 (0)

Values are number (%).

*Twenty-four-hour recall at study visits.

Improved Neurodevelopmental Outcomes Associated with Bovine Milk Fat Globule Membrane and Lactoferrin in Infant 8.e7
Formula: A Randomized, Controlled Trial
THE JOURNAL OF PEDIATRICS  www.jpeds.com Volume -

Table XIV. Gassiness at days 14, 30, 42, 60, 90, 120, 180, and 365*
Days Group None at all Slight amount Moderate amount Excessive amount P value
14 Control 0 (0) 56 (25) 168 (74) 4 (2) .164
MFGM + LF 0 (0) 70 (31) 148 (66) 5 (2)
30 Control 0 (0) 21 (10) 191 (88) 6 (3) .808
MFGM + LF 0 (0) 23 (11) 189 (87) 6 (3)
42 Control 0 (0) 16 (8) 189 (90) 5 (2) .045
MFGM + LF 0 (0) 28 (13) 179 (85) 3 (1)
60 Control 0 (0) 27 (14) 166 (85) 3 (2) .161
MFGM + LF 0 (0) 16 (8) 180 (91) 1 (1)
90 Control 0 (0) 38 (20) 155 (80) 0 (0) .218
MFGM + LF 0 (0) 30 (16) 157 (83) 2 (1)
120 Control 0 (0) 56 (31) 125 (69) 1 (1) .168
MFGM + LF 0 (0) 44 (24) 139 (76) 0 (0)
180 Control 1 (1) 61 (33) 122 (66) 1 (1) .138
MFGM + LF 0 (0) 48 (26) 135 (74) 0 (0)
275 Control 6 (3) 62 (36) 104 (60) 0 (0) .920
MFGM + LF 1 (1) 73 (43) 95 (56) 1 (1)
365 Control 3 (2) 74 (50) 71 (48) 0 (0) .715
MFGM + LF 1 (1) 79 (55) 63 (44) 0 (0)

Values are number (%).

*Twenty-four-hour recall at study visits.

Table XV. Stool characteristics at days 14, 30, 42, 60, 90, 120, 180, and 365*
Stool consistency
Days Group (n) Stool frequency P value Hard Formed Soft Unformed or seedy Watery P value
14 Control (228) 2.6  0.1 .659 3 (1) 19 (8) 143 (63) 61 (27) 2 (1) .481
MFGM + LF (223) 2.6  0.1 5 (2) 15 (7) 150 (67) 51 (23) 2 (1)
30 Control (218) 2.0  0.1 .905 1 (0) 34 (16) 145 (67) 38 (17) 0 (0) .466
MFGM + LF (218) 2.0  0.1 2 (1) 34 (16) 152 (70) 30 (14) 0 (0)
42 Control (210) 1.6  0.1 .682 0 (0) 32 (15) 147 (70) 31 (15) 0 (0) .118
MFGM + LF (210) 1.6  0.1 1 (0) 38 (18) 148 (70) 23 (11) 0 (0)
60 Control (196) 1.4  0.1 .505 0 (0) 33 (17) 148 (76) 15 (8) 0 (0) .197
MFGM + LF (196) 1.4  0.1 1 (1) 47 (24) 131 (66) 18 (9) 0 (0)
90 Control (193) 1.3  0.0 .643 0 (0) 51 (26) 134 (69) 8 (4) 0 (0) .516
MFGM + LF (189) 1.3  0.0 1 (1) 50 (26) 134 (71) 4 (2) 0 (0)
120 Control (182) 1.2  0.0 .648 0 (0) 52 (29) 123 (68) 6 (3) 0 (0) .585
MFGM + LF (183) 1.2  0.0 1 (1) 54 (30) 125 (68) 3 (2) 0 (0)
180 Control (185) 1.3  0.0 .319 2 (1) 69 (38) 111 (60) 1 (1) 1 (1) .370
MFGM + LF (182) 1.2  0.0 0 (0) 80 (44) 102 (56) 1 (1) 0 (0)
275 Control (172) 1.2  0.0 .777 2 (1) 109 (63) 59 (34) 2 (1) 0 (0) .756
MFGM + LF (170) 1.2  0.0 1 (1) 114 (67) 52 (31) 3 (2) 0 (0)
365 Control (148) 1.1  0.0 .669 2 (1) 120 (81) 26 (18) 0 (0) 0 (0) .560
MFGM + LF (143) 1.2  0.0 4 (3) 110 (77) 28 (20) 1 (1) 0 (0)

Values are number (%) or mean  SE.

*Twenty-four-hour recall at study visits.

8.e8 Li et al