UNITED STATES DEPARTMENT OF AGRICULTURE
FOOD AND DRUG ADMINISTRATION
FOOD ADVISORY COMMITTEE
MEETING ON INFANT FORMULAS
Tuesday, November 19, 2002
8:15 a.m.
U.S. Department of Agriculture
Animal and Plant Health Inspection Service Building
4700 River Road
Riverdale, Maryland
PARTICIPANTS
Temporary Voting Members Present
JAMES ANDERSON, Ph.D.
ROBERT D. BAKER, M.D.,
Ph.D.
SCOTT DENNE, M.D.
CUTBERTO GARZA, M.D.,
Ph.D.
JAMES H. HEUBI, M.D.
LAURIE J. MOYER-MILEUR,
Ph.D., R.D., C.D.
VIRGINIA A. STALLINGS,
M.D.
PATTI THUREEN, M.D.
MARGARET E. BRILEY,
Ph.D., R.D., L.D.
Participating Food Advisory Committee
GOULDA ANGELLA DOWNER,
Ph.D.
LAWRENCE N. KUZMINSKI,
Ph.D.
MADELEINE J.
SIGMAN-GRANT, Ph.D.
Acting Industry Representative
ROGER A. CLEMENS, Dr.P.H.
CNS FACN
C O N T E N T
S
AGENDA PAGE
Opening Remarks 4
Jose Saavedra, Nestle USA 5
Jon Vanderhoff, Mead
Johnson,
Bristol-Myers Squibb 19
Russell J. Merritt, Ross
Products
Division, Abbott
Laboratories 26
Barbara Heiser, Executive
Director,
National Alliance for
Breast-
Feeding Advocacy 35
Questions 41
Adjournment 219
P R O C E E D
I N G S
DR.
GARZA: I want to thank the committee
for assembling on time. We have a very
full schedule this morning, and we're going to try and conclude by 2:45 instead
of 3:00 o'clock because of some plane schedules.
I
think we can do this if we all are particularly careful in terms of addressing
relevant points, if the points have been made, not necessarily repeating them,
unless there are aspects of it that are novel to the argument, and we may have
to reduce break times and possibly bring your lunch to the table in order to be
able to conclude by 2:45, but I hope
that that latter possibility is proven not to be needed.
I
think there are no adjustments, other than those, to the agenda. Let me check to see if there are other
things that anyone else would like to raise regarding this morning's or this
afternoon's agenda, so we can plan accordingly.
[No
response.]
DR.
GARZA: No? If not, then, let's move forward.
I
hope that our three presenters for public comment are here, because we're going
to be starting a bit earlier.
I
have Dr. Jose Saavedra, Russell Merritt, and Jon Vanderhoof. Are they here? I know Russ is, because I saw him. Vanderhoof is here. And
Dr. Saavedra--he's going to the podium.
Very good. Okay.
Again,
we'll have 10 minutes for the presentation, and the timer will warn you when
your time is coming to an end. They'll
be gaveled quite strenuously, so I don't want anybody to feel picked on if I
interrupt you after 10 minutes, and then we'll go on to questions from the
committee after that--after the 10 minutes are up.
Dr.
Saavedra is the medical and scientific director with the nutrition division of
Nestle USA, and the comments are addressing when is a clinical growth study
needed.
Dr.
Saavedra?
DR.
SAAVEDRA: Thank you very much.
Thank
you very much for allowing us to be here.
I
want to thank Dr. Chris Taylor and Dr. Sue Walker for the opportunity from the
point of view of the agency, and certainly Dr. Garza and the advisory committee
or this ad hoc committee, for the opportunity to be able to address you this
morning.
We're
going to try to make our comments as limited as possible, but I do think that
it is important that we are able to bring to you a few of the points that we
think are relevant, particularly from the point of view of the industry.
I'm
Jose Pepe Saavedra. I'm associate
professor of pediatric gastroenterology and nutrition at Johns Hopkins
University School of Medicine and School of Public Health, and I'm here
representing Nestle.
However,
collectively, with Dr. Jon Vanderhoof and Dr. Russell Merritt, we hope to bring
to you a collective expression of the current status from the point of view of
when these issues that you've been grappling with over the last few days and,
actually, a few months, are important and how we address them as an industry
collectively here in the United States, speaking on behalf of the manufacturers
of infant formula in North America.
So,
we don't have much time.
I
want to go through a particular set of ideas that--as I said--together with the
following speakers will try to give you a glimpse of the kind of effort that
goes into the development of a thinking process and to the determination of
clinical trials and how we go about that on a regular basis.
And
the industry has currently a analysis and a process that is in place, that is
used, that has been used for years, in collaboration with the agency when it
comes to documentation and assessment for the use of clinical trials in
pediatrics and in nutrition, particularly when it comes to infant formula.
The
industry has a process and, as I said, a history through which it considers a
change to infant formula for a particular benefit.
Now,
we're not going to discuss claims, as it was mentioned yesterday. We're not talking safety. We can address that separately. Actually, that would probably be a whole
different conference.
But
we do have a process of assessment and documentation of all the important
nutritional--potential nutritional impacts that any change in infant formula
will bring about. This process exists
and this process has been ongoing, and it keeps renewing itself.
Throughout
the process and at the end of the process, each one of the infant formula
manufacturers notifies the agency of all major and minor changes and all the
rationale behind those changes and justifications for them.
Why
is that important?
Among
other things because we want to determine--based on the potential impact on
nutritional adequacy of that change, we need to determine the need for clinical
trials to confirm if an infant formula has and supports--has the
characteristics that support normal growth--i.e., is nutritionally adequate.
Now,
it is important to engage in a process that leads ultimately to that change,
because these clinical trials to be done to demonstrate nutritional adequacy,
of course, need and should be done every time we can reasonably predict that
there is a potential nutritional impact for that particular change.
On
the other hand, I think it behooves us, as people interested in children's
health and people interested in adequate running of trials and ethics, that we
do not do trials that are not necessary, that are not redundant, and that we
don't engage in the use of trials as a way around whatever potential change or
potential impact from the industry point of view we need to have.
Now,
this decision, ultimately, for the use of clinical trials in demonstrating
nutritional adequacy is based on a very specific reasonable and conservative
assessment of the potential impact of this change on nutritional adequacy, and
again, throughout this process that becomes transparent between the company and
the agency, we are always subject to review by the FDA.
Now,
the industry holds itself accountable in a number of ways, and certainly, one
of them is by a regular and clear process of notification to the FDA.
This
is traditionally done through two types of--through separate types of changes
which we divide into major and minor changes.
We don't have time to go into this, and it is not the subject of
discussion, but these changes, whichever, minor or major, all go through essentially
the same process of evaluation and clear understanding of the impact of that
change, with notification to the agency.
Only
if none of these changes apply then is it that the manufacturer continues--or
makes modifications.
In
essence, pretty much every aspect of the modification in infant formula, as we
know it today, truly undergoes a very complex set of assessments.
Now,
you have this in your hand-out. You may
have had a chance to go over it last night.
If not, you have 10 seconds here to memorize it.
But
what basically happens is--and what this represents here is the collective--the
collective decision tree or decision process that current manufacturers in the
U.S. go through in understanding what potential changes, whether minor or
major--and we will focus a little bit more on these--relating to packaging,
processing, formulation change, or the addition of new ingredients is taken for
ultimate decision on how this implementation of the change is going to happen,
what information needs to be done, what documentation needs to be present
before we do that.
What
is a major change?
There's
a number of ways to address it, but a brief definition is that it's any change
where a whole new infant formula is introduced in the United States by a
manufacturer that has never produced formula or a change in current formula
where experience and theory, particularly that experience and theory of the
manufacturer, predicts a possible impact on nutritional adequacy of the
product, or a change where there is a fundamental change in processing or
composition that also could potentially impact nutritional adequacy.
Now,
that change will lead all infant manufacturers to communicate on a regular
basis with the agency to document very convincingly to the industry itself, as
well as to the outside, documentation that demonstrates that this formula will
support normal growth.
The
nature of the change and the scientific rationale is what determines how much
work needs to go into this process before the change is implemented and how
much and what kind of supportive data are given.
Supportive
data is always necessary. There is no
change that is implemented without a clear process of assessment and
understanding of what the potential impact of that change might be, and of
course, that supportive evidence will and sometimes does include clinical
trial.
Now,
there is a whole process or exercise which is gone through for each one of
these changes or implementations.
First,
of course, we do go through what the published guidelines is, and I just do
want to echo a couple of speakers yesterday who indicated that these
guidelines, particularly, and a number of regulations need updated.
The
industry actually does not necessarily wait for this updating. The industry tries to maintain, as much as
possible, the scientific cutting edge from the point of view of what we
understand are, for example, nutrient requirements in infants.
We
don't wait, necessarily, for the final guidelines of somebody to show that we
need to do one or other.
It
was very clear yesterday, for example, that some of these regulations regarding
nutrient requirements in infants need revision. They're grossly updated.
But
the industry doesn't wait for that and, with notification to the agency, moves
along with these changes.
We
also have obviously looked at the literature, and pretty much every possible
discipline that could in some way modify the change--or, I'm sorry, modify the
conclusions with regards to that particular change is reviewed.
We
go through all the medical literature, the nutritional literature. We certainly bring into bearing all the
disciplines, whether it's chemistry, biochemistry, physical chemistry,
microbiology, to determine if this particular change might, in some or other
way, modify what we need to do.
Another
critical factor in this assessment is the experience of the industry, and
sometimes the experience of that particular manufacturer.
The
manufacturer understands--and most of them do, certainly here in the United
States--understand very deeply their product.
They know what goes into it.
They know how the processing happens.
There
is extensive documentation on all the physical, chemical changes, adulteration
changes that go on in a product that they already have and that they have
followed historically for years.
There
is a historical component of experience that sometimes only a particular
manufacturer will have on a particular set of nutrients or a particular matrix
or macro-nutrient.
Certainly
every manufacturer carefully measures and knows about its ingredients, its
batching and packaging processes, knows its nutrient stability throughout
history.
All
this needs to come into bear for understanding the potential impact of that
particular change that needs to be implemented, and of course, each
manufacturer also has a history of in vivo and in vitro testing in its formula,
in each type, in each component, its matrix, and of course, they have clinical
experience.
They
have clinical experience on clinical trials, for example, that ultimately will
help the manufacturer and ultimately those that are participants in the
process, in the thinking process, to determine if the clinical trials that were
done following or prior to this change still would support this potential change
without the need for other assessments.
DR.
GARZA: Thirty seconds.
DR.
SAAVEDRA: Now, once we go through that
large exercise, we also then, of course, engage in a very--sometimes very
deep--just like you were discussing yesterday--very deep discussions as to is
this going to make a difference or not, and even after that, when we're not
totally sure, then we bring people like you to discuss with the industry how do
we go about this change, what do we need to do, how do things need to move
along, are we doing the right thing, is there caveats we have not thought
about, and again, we communicate these back to the agency.
Certainly,
if, after looking at this whole process --
DR.
GARZA: I'm sorry, your time is up. Can you conclude?
DR.
SAAVEDRA: Yes.
DR.
GARZA: I'm sorry. You have 10 minutes, and if I give you more
time, I have to give everybody else more time.
We have 10 minutes per speaker.
DR.
SAAVEDRA: With all respect, what we had
requested is a 30-minute collective presentation.
DR.
GARZA: All right. You can continue.
DR.
SAAVEDRA: If, after all this, we are
still not convinced, then we do go on to the development of clinical trials,
and of course, clinical trials are necessary.
When
we talk about minor submissions over the last 10 years, there's been
approximately 100 minor changes submitted to the agency, approximately 360
major changes, and 50 growth studies in more than 600 children.
Collectively,
the U.S. infant industry has more clinical studies and growth studies than any
single institution or any single entity that we can identify.
Now,
what this has done, as mentioned before and in some of your papers--this has
produced infant formula that now essentially cannot distinguish, in this room,
who got infant formula and who got breast milk. We've made tremendous strides.
Nevertheless,
there is still a lot that needs to be done, and since that, here in the United
States, with this process in place and with this implementation, not a single
nutrition-based problem has resulted from formulation changes intended and
implemented by the industry here in the United States.
This
is the decision tree you will have. We
know we will never be able to reproduce breast milk. We'll never be able to reproduce the act of breast-feeding.
The
whole point of this process--and this is what you went through yesterday--as an
exercise, I believe, is try to go through each one of these changes so that
these changes will apply and allow you to make decisions which, again, I think
need to be made in the context of all this documentation that I mentioned
earlier, which makes it very difficult to make a decision for everything or
make a recommendation that is a blanket statement.
I
will now ask Dr. John Vanderhoof to continue our presentation. This particular aspect will relate to the
comparisons and groups that need to be incorporated into the measure of
clinical trial.
Jon?
DR.
VANDERHOOF: Thank you very much.
Until
eight weeks ago, I was an academic myself, and now I have this new job, and I'm
looking at this from a new perspective, and it turns out, I guess, it's
probably not all that different than how I looked at things before.
What
I want to do is just tell you very briefly a little bit about the
"what" part of the study process, and then Russ Merritt from Ross
will tell you a little bit more specifically about exactly how we conduct
clinical studies.
The
first point I want to make is that what we've been doing for the past several
years, since 1988, is based upon the AAP committee nutrition guidelines, and I
think these have really served us very well.
We've
had a longstanding history of producing nutritionally adequate formulas, and
whenever we do clinical studies, safety is, of course, a given.
This
is something that's well worked out during the pre-clinical phases. Those questions have, by and large, been
answered, and at this point in time, we're ready to demonstrate nutritional
adequacy with our formulas.
As
everybody mentioned yesterday, the timing of doing a formula study is very
critical. You need to do it during the
first four months of life, when infant formula is the sole source of nutrition
for the baby and the baby is most vulnerable and its most rapid growth phase,
so that we do want to study the formula at the time when its performance could
most likely be critically evaluated.
Weight
is the predominant end point that we want to measure. It's the most sensitive indicator of nutritional adequacy, and
it's our primary outcome variable.
Secondarily,
we measure length. One thing I learned
from taking care of lots of children with chronic liver disease is that weight
gain is not always a good thing, and so, we have to measure length, as well,
and I've added head circumference.
While we don't feel it's mandatory, it's a nice cross-check to have
available to us on length, and we can address gender differences by co-variant
analysis.
There
may be some instances when we might choose to look at specific laboratory
measurements or other body mass indices or something, and those are the times
when we might want to have a specific nutrient change or a specific nutrient
that we put into the formula that might affect one specific biochemical
parameter, and at that point in time, we would expect to introduce additional
laboratory measurements.
We
usually do double-blind, randomized prospective studies in most instances. This has been for many years the gold
standard for clinical research.
You
might say, well, why would you want to do this if growth data are inherently
objective measures and you know how babies are supposed to grow.
I
think there are a lot of times when we do clinical studies that we're also
interested in looking at some secondary parameters and we want to find out if
there are differences between the new formula and the old formula, and we might
also be interested in finding out if the incidence of adverse events that might
be picked up in the study are the same between an old formula and a new
formula, and at that point in time, we would definitely want to have a control group.
Our
studies are powered to detect a mean difference of 3 grams per day, and a
weight gain is a primary outcome variable.
This is based on the AAP guidelines, and since this standard was
adopted, there have been no product withdrawals because of nutritional
inadequacy, and we think that these guidelines have served us very well in the
past.
Presently
we're facing a bit of a problem in that there are a limited number of subjects
available because of the increased breast-feeding rate and a decreasing birth
rate, and we have looked into the possibility of powering studies to detect
smaller differences.
And
if you do the math on this, for example, if you did a study that required 500
infants, by the time you looked at the incidence of breast-feeding, the
patients that weren't acceptable, and then the number that--the 10 percent that
would actually volunteer and then the drop-out rate, you would have to screen
24,000 infants to come up with that 500, and at the present birth rate, that's
about the population that you'd see in new births in a city of 2 million
people.
So,
what other options are there?
Well,
there are basically historical controls and reference data. We have a large volume of that kind of data
available.
The
advantage of using reference data is it minimized drift over time and
identifies it. For example, if you look
at formula A and compare it to B and then the next study you do is compare B to
C and then C to D, each one of these formulas are a little bit different, so
they may statistically come out the same.
But
if you compared A to D, you might miss something, and you can pick that up when
you use historical data, and if you didn't have to have the control group, then
you might be able to power the study at a little bit higher level.
Ideally,
most of the time when we conduct research, this is what we would want to
do. We would want to use concurrent
controls so that we could identify these other things that we talked about,
like the incidence of adverse events and so forth.
We
would want to compare the mean data that we have to the mean reference data to
make certain that we don't have any drift, and the vast majority of times, or
at least frequently, this is the kind of study that we want to do.
So,
in summary, we think that the present criteria that we've utilized since 1988
provide an ideal balance of allowing very nice research to be done on infant
formulas and, at the same time, protecting too many infants from undergoing
formula studies and subjecting an excessive percentage of the population to
studies.
We
think that the present guidelines have resulted in superior infant formulas and
an excellent record of ensuring nutritional adequacy for our population.
Powering
the studies according to the AAP guidelines has produced an excellent safety
record, and we're very happy with the results that we've had using these
guidelines.
Regarding
the specific questions that you may be pondering at the moment, it's our
opinion that concurrent controls in formula studies are usually desirable but
in some instances may be unnecessary, and it may be appropriate to use
reference data in some form.
We
also feel that most of the time the weight and length measurements and head
circumference measurements that we talked about are the primary variables that
we want to address, but occasionally other biochemical or body mass
measurements might be indicated in specific circumstances where the particular
study might indicate their value.
I'd
like to now introduce Russ Merritt from Ross Labs, and Russ will tell us a bit
about exactly how we conduct growth studies.
DR.
GARZA: Thank you, Dr. Vanderhoof.
DR.
MERRITT: Thank you for the opportunity
to address the committee this morning.
I'm going to pick up where Dr. Vanderhoof left off and talk a little bit
more about the "how" of conducting studies.
The
infant formula industry has provided you a sample growth protocol for infant
growth studies that reflects our experience with conducting such studies since
before the inception of the Infant Formula Act in 1980. I hope you've had an opportunity to review
it.
There
are a number of specific aspects of this study design that I'd like to call
your attention to.
The
first is to recognize the purpose of a regulatory growth study.
We
need to remember that infant formula is food, food for a vulnerable population
and, at times, the sole food, but still food.
This
food supplies the nutrients required for infant growth within a range
considered acceptable.
We
need to specify testing of new infant formulas that provides assurance that
they support growth during the fastest period of human growth, when it is used
as the sole food in the diet--that is, in the first four months of life. After four months of age, the common use of
other foods in the diet make it much more difficult to assess the data in a
growth study.
The
method of achieving this is to demonstrate that a proposed new infant formula
performs at least as well as a current commercial formula appropriate for the
population under study. In some special
situations, additional claims may be sought and additional studies or end
points will be needed.
Now,
as far as control groups are concerned, accepted clinical practices generally
require the comparison of a new intervention with a standard current of practice--in
this case, a marketed infant formula.
To
put the growth study in an historical context, the growth data are always going
to be compared to some reference standard such as the CDC 2000, the Iowa data,
or internal historical data, which may be more extensive than some of the
reference databases.
So,
in effect, a current control and an historical reference play different roles
in the growth assessment.
The
use of an exclusively breast-fed reference group, historical or concurrent,
assumes that the group of formula-fed infants should grow identically to this
group.
As
of today, no well-recognized standard for exclusively breast-fed infants
exists, thus the WHO study we heard about yesterday that is underway.
We
cannot assert at this stage that we know that the growth of a breast-fed and
formula-fed infant should be identical or that a specific feeding regimen has
unequivocally been demonstrated to be better than others from the perspective
of long-term growth and body composition.
Furthermore,
different initial growth patterns may turn out to be preferable from the
standpoint of different clinical outcomes--for example, neuro-development,
obesity, cardiovascular risk, etcetera.
We
move to one-sided versus two-sided.
One-sided
testing addresses the critical question of whether the new formula performs at
least as well as a current commercial formula.
That's
the question we need to address, and in contrast, two-sided testing, as usually
performed, is less sensitive because it dilutes the power.
If
we look at the sensitivity to measure nutritional adequacy, it's not certain
that very small differences between groups are necessarily meaningful.
The
existing de facto standard of 3 grams per day, approximately a half a standard
deviation, appears to have served us well.
At this stage of our knowledge, we simply do not know the best infant
growth pattern, especially not for the individual infant in a study.
For
context, please bear in mind that studies to define longitudinal growth status
that are underway--for example, the WHO multi-center study--are actually
smaller than the studies that some food advisory committee consultants have
suggested to verify that a single new infant formula, which will already be
known to contain the necessary nutrients, supports growth.
So,
some of the suggested protocols are actually greater, numbers of subjects are
actually greater than what is being used in that study.
We've
also heard repeatedly from the consultants that it's a misuse of the available
science to pretend we understand the health implications of a gram or two of
weight gain per day for a short period in human life or to define an
extraordinarily specific statistically-driven definition of a single rate and
pattern of infant growth as the only one that is normal or even acceptable when
testing infant formula.
What
we're trying to get to is an actionable protocol. The growth protocol provided by the industry acknowledges the
important need to continue to provide assurance that new formulas support normal
growth.
Although
the outline submitted is brief, the actual protocol may extend to 80 pages or
more, as specific details are filled out in a specific instance.
The
Infant Formula Act places a responsibility on manufacturers to demonstrate that
their formulas can function adequately as substitutes for human milk.
To
date, the manufacturers have met this obligation effectively, often through the
use of a growth study.
The
growth protocol utilizes the current scientific approach of a randomized,
blinded, control trial in conjunction with well-characterized reference data
for infant growth.
A
couple of comments on the evolving context in which we do these studies.
This
is not a static environment. The nation
is coming closer to the Health People 2010 goals for breast-feeding. This will have the effect of reducing the
number of exclusively formula-fed infants available to participate in clinical
trials.
In
addition, evolving ethical standards may further limit the types of studies
acceptable in pediatric subjects.
Such
changes may make it increasingly difficult to complete even the growth study
protocol which industry has used.
Thus,
rather than moving to more restrictive protocols, other approaches regarding
study participation, eligibility, and/or fewer subjects for the use of historic
references may need to be considered in the future.
The
current system has effectively protected the public health while allowing more
than 20 new infant formulas to enter the marketplace in the last 10 years.
We
welcome a more predictable process and regulatory environment, as well as the
collective expertise which the Food Advisory Committee and the FDA have brought
to bear here today.
However,
in your deliberations on these issues, we do ask that you be mindful that more
restrictive standards may not achieve any greater assurance of nutritional
adequacy but could substantially reduce the ability of industry to bring the
benefits of new science to infant nutrition in a timely fashion.
Thank
you for the time.
DR.
GARZA: Thank you, Dr. Merritt.
We
have a choice--we have one more speaker that has come forward--to hear the
additional speaker and then ask questions to all four, or you can--we can take
the time now to ask questions to the first three speakers. Is there a preference among the group?
Do
all four? That would be my sense, as
well.
I'd
like to then call Ms. Barbara Heiser--I hope I'm pronouncing that name
correctly--executive director of the National Alliance for Breast-feeding
Advocacy.
Ms.
Heiser, I'll warn you about 30 seconds before your 10 minutes are up.
MS.
HEISER: Thank you for taking the time
this morning to let me speak before the committee. My name is Barbara Heiser.
I am the executive director of the National Alliance for Breast-feeding
Advocacy.
I'm
a registered nurse and also an international board-certified lactation
consultant.
I
guess, to start with, yesterday, as I sat and listened from the back row, I
wanted to stand up as we talked about optimal infant feeding and say wait a minute,
we're mammals, our milk is species-specific, human milk for human babies. That's optimal feeding.
That
doesn't mean that the other formulas and all aren't important and shouldn't be
good. They should.
But
we know optimal feeding is exclusive breast-feeding for six months, not even
four to six months, six months. That's
been decided after at least--I've been in discussions internationally for 12
years on that subject.
It
has been reviewed, literature, research, everything, and optimal feeding as exclusive
breast-feeding for six months has now been agreed upon by the American Academy
of Pediatrics, by the Surgeon General of the United States, as well as WHO.
So,
I think that has to be our standard.
Does it mean that formula feeding has to have the same growth
pattern? I don't know. But when we say there has to be a standard,
we should have the standard that we know is best for babies.
The
other thing that NABA has worked on very hard is speaking for breast-feeding
moms and babies.
We
don't speak for any group or professional organization; we speak specifically
for breast-feeding.
As
a mother, I don't think the government agencies understand how much trust the
general public put in you.
When
a formula--when something new comes out, they've heard all the reports about
how drugs take years and years and years to go through testing before they go
to the public and they think that's true of everything.
Recently,
with the addition of the long-chain fatty acids--DHA and ARA--moms think it's
wonderful.
However,
the marketing has been so wonderful that mothers are afraid--well, they're
happy. They call me up and say which
formula has the breast milk in it.
And
then yesterday I got called--and you'll appreciate this if anyone's from
California. It was from California, and
a mother went to the WIC program, because they're working on contracts right
now, for the new formulas, and she says whose breast milk is in the
formula? I want to know, because I want
to know if it's safe. Okay.
That's
how it's been perceived, and we know that the DHA and the ARA that's been added
is fermented micro-algae and soil fungus, whatever it has taken to produce
this--these aren't even in our normal food chain, and we're having a lot of
babies have problems with this.
Now,
yesterday, one thing that had not come to my attention previously was the
liability factor as far as hospitals, food poisoning, adverse events.
Most
of the people working at ground zero with moms and babies don't know lots of
babies have allergic reactions or problems with different formulas.
That's
why there's so many out there for them to try and why each company makes
different kinds.
But
we're seeing a lot more explosive diarrhea with this, and we've been wondering
why some of the reports--in looking at post-market surveillance, just in my
mind as a mother and an advocate for women, I worry that the 4 million babies
being born in the United States are being guinea pigs for post-market
surveillance without the mothers knowing that it's being looked into if
formulas are safe.
They
think it's already been through 10 or 12 years of testing, and I know the
companies do a lot of testing, and I appreciate that, and I want to say that I
believe infant formula is a very necessary part of our society. I was a NICU nurse. It's very important. But I want to make sure it's the very best
product and it's perfectly safe for our babies.
Also,
as a mother, we talk about easy growth measurements--height, weight, head
circumference--very easy to get, very now, but that wouldn't be what I want to
know about this food to my baby.
I
want to know that it's giving everything, and we know that the important thing
for growth for human babies is brain and neuro-development, and so, I really
ask the committee to look at the regular growth parameters. They're very important.
But
you have to have some looks at the neuro-development, also. It's been hard to find because of the
marketing.
I
mean I hear the companies now say that there's less totally artificially-fed
babies out there, formula-fed babies out there, and that's funny, because we've
had the same thing on the breast-feeding side.
Because
of marketing and supplementation, there's been fewer and fewer exclusively
breast-fed babies out there.
But
we need to look at it, and I was excited yesterday, hearing about what you're
doing, because I thought, you know, okay, we know optimal breast-feeding is
exclusive breast-feeding for six months.
Now,
as FDA is doing some studies on new formulas and ensuring, the topic was brought
up, you know, well, how do we know if a new formula starts the growth pattern
of a breast-fed baby that it's really still meeting the nutritional needs? Well, if you're doing your study right,
we'll know, and we'll have the proof that the formulas are just as good as they
can be, and I think that would be very important.
The
last thing I want to say is, once again, mothers expect safety from the
government more than you know.
They
expect great products from the companies.
You have a great burden. When a
health-care provider gives a mom that discharge bag full of the goodies, it's
like the health professionals are endorsing that product to them.
And
so, what I ask of you on this committee is, as you deliberate and set up growth
standards, please know that breast-feeding is optimal for six months, and
please find out what's best for babies on infant formula and what's the safest
for them.
Thanks
so much.
DR.
GARZA: Thank you, Ms. Heiser. Before you leave the podium, don't take your
microphone off. There may be some
questions, and we'll take questions.
Does
the committee have any questions of Ms. Heiser?
Dr.
Stallings?
DR.
STALLINGS: Thank for being with us.
As
a point of clarification, I'm not sure that the American Academy of Pediatrics
Committee on Nutrition has endorsed six months of exclusive breast-feeding.
MS.
HEISER: In their latest statement, they
have.
DR.
BAKER: I'm a member of the Committee on
Nutrition, and we have not. The
official policy of the Academy of Pediatrics is still four to six months.
There
is a new yellow book coming out which will have new recommendations, and it's
not decided yet what that will say.
MS.
HEISER: I'm sorry. I gave that information from the United
States Breast-feeding Committee on which AAP does sit, and Dr. Larry Gartner
gave it to us. So, if I mis-quoted, I
am sorry, but I had it from a primary source.
DR.
GARZA: Are there other questions?
Ms.
Heiser, you mentioned that there's an increased rate of diarrhea and other
illnesses or intolerance.
Is
that from monitoring information that your organization collects, or is that
based on your professional perception, or can you give us a bit more
information on that?
MS.
HEISER: The information I can give,
unfortunately, is only anecdotal, but as a organization, we do collect
information. We encourage mothers to
report adverse events via Med-Watch and to report to the companies, as we do
when we train nurses, etcetera, and we've been doing this for the past several
months, because initially, when I heard of it, I just thought it was one
incident, and then I heard it again, and we lecture throughout the country, so
we have had a pretty good report.
The
most recent one came from the State of California, the WIC program.
A
lot of the mothers there were buying formula on their own because they wanted
the best for their babies, and they reported large number of cases of explosive
diarrhea, to the point that the WIC director, when they were looking at the
contracts for the upcoming year, was concerned if that was the only product
they were going to have available to their population.
DR.
GARZA: Any other questions?
Dr.
Downer?
DR.
DOWNER: Thank you for putting a human
face to this.
I
wanted to find out, with respect to the anecdotal evidence that you've been
collecting, have you looked at all at how the formula is being handled with
respect to safety issues, to see if this may be impacting on, for example, the
explosive diarrhea that you mentioned today?
MS.
HEISER: Yes, we do question that. We've been asking specifically health
professionals with babies in NICUs and in the hospital setting where we have
total control to really look at that issue, so we'll have some information. As of yet, that hasn't been gathered.
But
from the general population, we're getting more cases of it, and these are the
same people mixing and doing other formulas, too, without it.
So,
I see them as their own control group, because they're using both kinds.
DR.
GARZA: Dr. Stallings?
DR.
STALLINGS: I was interested in your
comment that the public perceives infant formulas as, in essence, being managed
more like drugs than like food.
Could
you make a few more comments on that and the basis--the information that led
you to make that summary statement?
MS.
HEISER: Okay. The reason is, initially, with health-care providers, because a
lot of the information goes into food and drug through Med-Watch and also
because of the promotion by the companies to hospital personnel, they are
treated as vendors on the--you know, as drug vendors more than the PO office
for the foods down in the cafeteria, okay?
So, that's the beginning of it.
The
other is, as claims come out, health claims and all, as that comes out, then
people look at formula as more than just a bowl of cereal, okay?
They
know it's important because the Academy of Pediatrics has said don't give
regular milk for one year. You know
that the baby needs more in its growing time, that it's very important that it
has this thing.
We
still have grandmas around that remember pediatricians making up their own
special concoctions of formula to meet those nutritional needs.
So,
this is where that perception comes from, that it's not just something you can
go out and get.
DR.
GARZA: Thank you very much, Ms.
Heiser. We certainly appreciate your
taking time with the committee this morning.
And
I'd like to ask Doctors Saavedra, Merritt, and Vanderhoof if they would please
come up, and I think it will be easier for us to ask questions if the three of
you are up at the podium, assuming that we will have some.
Dr.
Stallings?
DR.
STALLINGS: Thank you gentlemen for
being with us.
I'm
interested in having you discuss the issue, really, as the one-tailed versus
the two-tailed analysis, because I think all of us--and I certainly know,
including all of you, are interested in the issue of over-nutrition, as well as
under-nutrition, and that seems to be one of the core issues that we're dealing
with.
So,
could you make a few comments and, in some ways, try not to do the practical
issue, because I'm asking you more of the theoretical question now.
I
know it takes twice as many subjects or almost twice as many.
Thank
you.
DR.
MERRITT: I'll start, since I brought
that up.
The
historical context has been to assure nutritional adequacy, and in that
context, if you look at how the study is designed, if you were to put all of
your power on the lower half of the study, then, in effect, you have greater
sensitivity to detecting a problem on the low side.
Relative
to additional protections on the high side, as Jon and I both noted, we not
only will generally compare a new formula or a modified formula to an existing
formula but also then check these data against a reference standard, whether
it's CDC 2000 or Fels, etcetera, and in general, what we find is concurrence of
the two answers.
I
think if you--if we were in a situation where there was not concurrence of
those answers, we would, you know, do some additional thinking and some
additional assessment.
So,
I think you have the dual assurance of somewhat greater sensitivity on the low
side but also the cross-check against your historical norms.
DR.
GARZA: Dr. Denne?
DR.
DENNE: You told us there had been 150
major changes and 50 clinical studies, and I was wondering if you could tell
us--give us an example or two of a major change that didn't require a clinical
study and the rationale behind that.
DR.
SAAVEDRA: There's a number of examples.
For
example--and there's many ways to try to understand the--I think what's
critical is understanding the process, the thinking process, because that's
really what you're all charged with, is understanding if that major change--for
example, a particular ingredient in a new formula--is going to be impactful
from the point of view of nutritional adequacy.
So,
a particular ingredient can be added to a formula that has slightly changed
from the point of view of the manufacturer's matrix over a period of time, and
we add that ingredient, which has already been tested, which is already GRAS,
which has already been analyzed biochemically in terms of nutrient stability,
in terms of physical chemical stability, in terms of possibility that could
adulterate other products and so on and so forth.
So,
because it is a new ingredient to that particular product--for example, a soy
formula versus a milk-based formula--then that is a major change.
However,
extensive experience with the basics of understanding of that ingredient, as
well as the formula, and all the interactions that could possibly happen, that
we could identify within that--for that change don't necessarily mean that you
need to study 100 or whatever number of children to demonstrate that it is safe
and that the formula hasn't changed from the point of view of providing
nutritional adequacy.
So,
these are major changes, and they're classified that, and I don't think we're
going to go into the discussion of a particular major change.
But
this is an example in which a growth study would essentially be unnecessary if
there has been all the evidence from the point of view of the ingredient, from
the point of view of the product, and the manufacturer's understanding--I think
this is critical also to understand that each manufacturer knows very well its
matrices, its proteins, its fats, and every ingredient that goes in there, so
that this predictability from the point of view of potential nutritional impact
can be established.
DR.
GARZA: Dr. Anderson?
DR.
ANDERSON: I'm going to suggest two
criteria for the setting in which clinical growth studies are not required and
ask you to comment.
The
first would be that they would be required only when there is a reasonable
basis to predict that a change to a formula will materially impact nutritional
adequacy or otherwise have a significant adverse impact.
The
second would be that they're not required when the preponderance of the
evidence suggests that a change will not affect the ability of the formula to
promote normal infant growth.
The
emphasis is really on--I've tried to formulate these in a way that--in the
first instance, the assumption is really that the change is safe unless
otherwise--unless thought otherwise, and in the second instance, one needs to
demonstrate safety in order not to proceed with a study, and I wondered if you
could comment.
DR.
VANDERHOOF: I'll try that one.
First
of all, I think if there's reasonable likelihood that--or even a reasonable
suspicion that the formula might adversely affect growth, we probably would
choose not to even test that.
So,
we would only want to test a formula clinically that we were quite certain was
nutritionally adequate.
And
then to take that a step further, I think unless we were extremely certain that
there would be no adverse effects on growth, we would want to do a growth study
on the babies and particularly any kind of an ingredient change or anything
that might somewhat affect any parameter that involves growth, such as the
changes in the hormonal milieu or tropic factors or anything like that that
could be secondarily affected, would certainly trigger a growth study to be
done.
I
think there are other instances, as Pepe mentioned, when certain ingredient
changes would predict absolutely no effect on growth, and in that instance, you
may not need to do it if the manufacturer has extensive experience in that
regard.
DR.
GARZA: Dr. Stallings?
DR.
STALLINGS: You all were with us
yesterday when we had the good fortune of having Dr. Fomon recap some of the
history that, you know, I'm sure informed the 1980 law and then the 1988
Academy of Pediatrics advisory group which put together the things that we're
currently operating under.
And
at that point, he was saying that the 3 grams a day, you know, basically was an
opinion at that point based on those data and a little bit of good clinical
judgement, which often informs all of it, and then yesterday we had, if you
will, a group getting together and considering the same thing, and my sense of
what we heard yesterday is that 3 grams a day difference may be higher than it
should be and that we might be well-informed to reduce it a little bit.
So,
I was interested in your comments, knowing all of you have been through the
opportunity to serve on consensus committees and recommendations and that sort
of thing, but I think I was hearing that that number, which may have served us
well in the past, might need to be revised.
I'd
be interested in your opinion on that.
DR.
VANDERHOOF: I'll give you my opinion,
and then maybe this is an important enough topic that we probably all ought to
comment on it, but this is an arbitrary number. I think that's probably where it came from. Somebody had to pick a place to start.
Here
you try to strike some kind of a balance.
You
know, if you want to do a controlled study with a control group and get an
appropriate number of babies and whatever and you power it to that level, I
think it's reasonably practical in terms of not subjecting too many babies to
clinical studies and, at the same time, getting the information that you need,
and remember, this is where we power the study, and in actuality, what happens
is that the curves are normally quite similar, and that's not to say that we
expect to see that kind of a difference.
I
think if you go beyond that, then you have to start looking at other situations
where you might need to eliminate control groups, and that then has a negative
on the other side of the equation.
So,
there may be instances where it might be necessary to power the study
differently, but I think for the vast majority of cases, this is probably adequate,
and it's certainly done well for us in the past.
Russ?
DR.
MERRITT: I think if we had greater
assurance as to what's best, I could have more enthusiasm for trying to get
closer to that standard, but in the absence of that knowledge and the history
of protecting the public health with the 3-gram standard that seems inherently
reasonable, as well, I'm not convinced we've made the case that, in fact, a
different standard will give you additional assurances.
It
will certainly increase the time and the number of babies and such that will
have to be involved in the studies in order to bring new formulas or make
changes in formulas.
So,
I think in the absence of that kind of certainty about the standard, it makes
it very difficult to rigidly pursue it.
I've
looked into, you know, the historical differences that we've seen recently, and
although we've powered the studies for 3 grams, in almost all instances the
actual difference is quite a bit less.
DR.
SAAVEDRA: I just want to add--I
certainly concur with what Russ and Jon said, but I do think that, aside from
that--and certainly I'm trying to understand as best as possible what is ideal,
which I know none of us can actually say what is ideal.
In
the absence of that, it is striking the balance between what is practical, what
is doable, and what is beneficial.
I
mean I think the goal here, if we want to do something that allows us to make
improvements and enhancements in infant nutrition--and we have--as we said
before, we've come a long way--it's striking the balance that we as--and all of
you as academicians have to grapple with all the time, and these differences of
three grounds that we're talking about is between the control and the
experimental group.
As
we discussed, for example, in Jon's talk, there can be drift. The difference may be 3 grams for that group
but may not be with the reference population or may not be between two
different groups that were compared to the reference population.
So,
until we know what is the right one that we're comparing to, then trying to
find minute differences and smaller and smaller differences--which, of course,
in the ideal situation, in the non-human situation, which is the ideal one, it
would be doable--we need to do our best to strike that balance, and I do think
we need to take history into consideration, and I did mis-quote, I said 600
children instead of 6,000 children, but that's the kinds of numbers that have
evolved into having the kinds of formulas that we have now.
DR.
GARZA: Rather than addressing the
3-gram issue, I have a more generic question.
Each of you referred--I think each of you referred that you would be
supplying data demonstrating the support of normal growth. What is normal growth, from your
perspective?
DR.
MERRITT: What I thought I took home
from yesterday's comments here was that there are a lot of opinions based on
our scientific experience, based on our bias, based on our personal preference,
but a definition of normal beyond the context of what has historically happened
is very difficult, and I think the knowledge has simply not reached that state.
So,
I think we have a default definition of knowledge of normal that reflects, for
example, in the first few months of life, NCHS or Fels or the historical data
that are available to us and that, much like, you know, an acceptable daily
intake, this is the experience that appears to be associated with reasonable
health.
DR.
GARZA: Dr. Merritt, before you pass on
the mike, in the absence of ideal information, which we often deal with in
medicine, we often to go to defaults and often in terms of normal physiology
and history.
I
have not understood the rationale for saying that, in fact, one can't use, in
the absence of whatever one might define as ideal information, the growth
patterns of breast-fed infants as that normal standard, and notice I didn't use
the term "reference" but "standard," precisely for the
reasons that you've outlined, that, in fact, we don't have ideal information
available to us and that we have to depend on some default and that, until
proven otherwise, the breast-fed infant becomes that standard.
What
is faulty with that rationale?
DR.
MERRITT: I think we already know that,
at some stages, probably less in the first three to four months than
subsequently, there are some differences between the breast-fed and the
formula-fed infant.
We've
also seen that, by approximately two years of age, they appear to come a little
closer together, and picking up on something I think Jon said earlier this
morning, I don't think, at 10 years of age, we have the ability to look back
through the retrospectoscope and say who was breast-fed versus who was
bottle-fed.
And
we certainly, at this stage, do not know the implications for, you know, the
chronic diseases of later life, as well as even neuro-developmental issues, as
to what particular mode of feeding or combination of foods or combination of
breast-feeding with or without supplementary foods is truly going to give us a
particular outcome at some lengthy time point remote from the feeding
experience.
DR.
GARZA: But if that's true--I need to
press this, because it's an issue that we're going to be dealing with once you
get off the podium.
If
that's the case, then we have a historical experience of millennia with human
milk feeding, a rather recent experience with formula feeding.
In
the absence of that type of information, why not use the breast-fed infant as
the default?
I
mean I am failing to understand the rationale that, because we don't have
information, then, in fact, we have to rely on historical information, but if
we rely on historical information, then we've got the historical information of
the feeding patterns for millennia. How
do we get ourselves out of that bind?
DR.
VANDERHOOF: Well, let me make a
comment, and then I'll turn it back to Russ.
As
a clinician, we've all had experiences in dealing with children--breast-fed
children with failure to thrive, and one of the first things that you do is
change the mode of feeding and find out how well the baby gains weight.
And
very frequently, the baby will markedly increase their formula consumption and
they'll gain weight very rapidly, and when you look at the feeding patterns for
breast-fed babies, I think you have to consider that there are probably a fair
number of babies in that group that are probably not getting as many calories
as they might want, because the process of feeding the baby is different.
And
so, if you simply look at this as a nutritional component problem, I think you
may be missing the differences in process, that the process of breast-feeding,
the interaction between the baby and the mother, the cues for the baby
determining when--and the mother determining when the baby's had enough to eat
and so forth are all significantly different, and so, this factor--these
factors may influence the differences in weight gain, as well as nutritional
factors.
And
if we go back--and then, within infant formula--I think somebody brought this
up yesterday--I'm not sure who it was--if we go back and try to replicate that
by changing the nutrient mix in the formula, we may end up depriving the baby
of essential nutrients that it might otherwise need.
So,
I think the problem is there's an additional difference in process, as well as
formula.
DR.
GARZA: Without a standard, Dr.
Vanderhoof, what prevents the formula industry from manipulating the
composition to match any other standard or any other reference?
If
one can do that to, in essence, match the breast-fed infant to create the sorts
of problems you just described, doesn't that argue that, in fact, one could do
it in the other direction, as well?
DR.
VANDERHOOF: We could probably make a
formula that could duplicate the growth curve of a baby that's breast-fed, but
you'd have to do it by making a formula with the caloric density significantly
lower than breast milk, and it's been our standard to try to replicate as
nearly as we can what's in breast milk when we create the formula.
So,
the only other way to do it would be to feed the baby less milk.
DR.
GARZA: In fact, that would not meet the
nutritional standards of present law if you did that, right, if you manipulated
it in that fashion.
DR.
VANDERHOOF: That's right.
DR.
GARZA: Okay.
Are
there other questions?
Dr.
Heubi?
DR.
HEUBI: On a totally different vein, the
question that was raised, I think, by Ms. Heiser this morning was one that I
think we addressed at our last meeting here, and that was the reporting of
adverse events related to formulas, and the comment was made--and I don't remember
who made it in April--the comment was made, I think, that many reports are made
to companies that don't come to Med-Watch regarding adverse events related to
formulae, and Ms. Heiser was making this comment about introduction of a new
formula, and now there are myriad complaints.
Can
any of you comment about this and how this work vis a vis the agency and the
individual companies?
DR.
MERRITT: In accordance with the Infant
Formula Act, we each have mechanisms for both recording and assessing all complaints
of any type relative to infant formulas that are reported to us, and the FDA
examines those on an approximately annual basis to--along with us--identify any
potential issues that may have emerged.
And
we are highly responsive and, I think, responsible in this regard in terms of
the effort that goes into the record-keeping and the assessment of those
complaints, and in some instances, for example, when a new formula is marketed,
we will review those at periodic intervals to make sure there isn't something
happened in the marketplace that we had not been seeing previously. So, I think those safeguards are in place.
DR.
HEUBI: Let me ask one question beyond
that, and that is there was--there's been discussion, at least at the NIH and
other agency levels, about having independent monitoring boards, and I know
that most industry has their own internal, and then there's this obvious
potential for conflict of interest in terms of that particular scenario,
reviewing your own data, saying, oh, there's not a problem. Can you comment about that?
DR.
MERRITT: I think for a standard growth
study of the type that we're describing here for changes within the realm of a
change in the formulation but not a dramatic change in claims, for example, on
the formula, there is enough experience and enough guidance in the form of the
International Conference on Harmonization and the like relative to how these
studies are conducted that I think that would be, at least in my impression, an
unnecessary degree of oversight.
Now,
there may be special situations when you're studying special populations and
making more novel interventions when an external advisory board may, in fact,
be indicated.
DR.
GARZA: Dr. Briley?
DR.
BRILEY: Yes. I'd like to ask a question.
I
understood that you said that, when you did a product testing such as soy, that
you knew all the scientific background and all of the chemical background, the
physiological background, but I guess I didn't understand or maybe you didn't
come across--how would you know if that product was absorbed, utilized by the
child unless you had done a clinical test with that new product?
DR.
SAAVEDRA: What I was talking about is,
for example, the addition of a particular change in a ingredient in a soy
product that has been used and has clinical trials already.
Of
course, a change in the protein, a change in the protein source is what would
be considered a major change, and actually, that would be a very good example
of a time where you do need a growth study, if you're using a protein that has
not been used before.
So,
from that point of view, absolutely, this would be a very good example of one
of those situations where a clinical trial is pretty much self-evident from the
beginning.
DR.
MERRITT: Bear in mind, that would be
done in the context of what was already known, for example, from the animal
literature and the like that demonstrated the availability of the protein
source.
DR.
GARZA: We are going to give Dr.
Kuzminski the last question, so we can stay on schedule.
MR.
KUZMINSKI: One of you--I believe it was
Dr. Saavedra--described the use of pre-clinicals, both in vivo and in vitro,
prior to clinical testing.
Could
you provide us with a little bit more detail on what these pre-clinicals are
and some idea of the reliance on the use of them in contrast to going to a
full-scale test?
DR.
SAAVEDRA: Yes.
The
in vitro studies have to do with a number of characteristics of the product
that relate to chemical, bio-chemical, physical chemical studies that are actually
done in the product to measure the stability of the ingredient, the fact that
the ingredients that were previously there didn't change, didn't become
adulterated, and so on and so forth.
So,
there's extensive trial work that goes on, typically, at the--what is part of
the R&D phase of a particular product to make sure that, from the
structural, chemical, and physical chemical characteristics that might in some
way modify a particular or interact with another particular ingredient within
the formula don't happen.
If
they do, then, of course, this typically requires further assessment to decide
if this is even a viable product.
Many
times the change is dramatic enough that there is not worth in continuing that
kind of modification, because the in vitro work actually demonstrates that the
change is significant enough that it might actually have more nutritional
impact that you would think.
I
do want to emphasize that once we go to the clinicals following those studies,
it's because we have--for the most part, the industry feels very reassured that
there is no nutritional inadequacy.
I
can assure you--and I'm sure you all as clinicians would not test a product
that you don't think is going to be the same or better. That happens only after you've gone through
this, as I said, extensive exercise where you do this kind of testing to
understand better these changes before you even give them to animals and then
before you give them to humans.
MR.
KUZMINSKI: So, the in vivo part of the
pre-clinicals are animal-based.
DR.
SAAVEDRA: Usually, yes.
DR.
GARZA: All right. I certainly want to thank the three of you
for your patience with the committee and your help in our deliberations. Thank you.
DR.
SAAVEDRA: Thank you.
DR.
GARZA: On the agenda are final
questions to invited speakers. I don't
want to--I think the word "final" is perhaps too final. I think that most of them have been willing
to stay throughout the meeting and will be available to us, but having
reflected on the discussions yesterday, I want to check with each of you to see
if there are any questions you may have to any of the presenters before we
continue with question four, where we left off yesterday.
Dr.
Stallings?
DR.
STALLINGS: I felt like, after
yesterday, I had a much better understanding of how modern breast-fed and
formula-fed infants grow compared to the different references, but I didn't
think I came away with quite as clear an idea of how breast-fed and--modern
breast-fed and formula-fed babies are growing compared to each other, because a
lot of the demonstrations we saw were really reflecting the idiosyncrasies of
the growth grids that we have today and how--going from the '77 to the new 2000
and potentially to the WHO.
So,
I wondered if Ed or someone might be able to address looking at that and trying
to focus on the difference in growth in the first four months or the first six
months.
DR.
GARZA: Ed, do you have any of those
charts with you?
DR.
STALLINGS: I don't know if it's
helpful, but that's why we had the chart brought in.
DR.
FRONGILLO: Well, let me tell you what
I've done, and you can ask me how you want to display it, okay?
Virginia
asked me about this first thing this morning, so I was sitting here playing
with my computer, calculating these rates.
I
have brought with me--happened to bring with me the Iowa data and also some
data from Newfoundland that Alex Roach and team collected.
The
Iowa data are expressed in terms of rates from eight to 42 days and then from
42 days to 112 days, and basically, there, in the eight-to-42-day period, there
is really no difference for males or females in rate between breast-fed and
formula-fed.
So,
in the early period, from eight to 42 days, there was no difference, but in the
period from 42 to 112 days, roughly a little past a month to almost six months,
that--four months, I'm sorry--that there were differences for weight of about 3
grams per day, with the formula-fed being faster, and a difference--a really
quite small difference in length, in millimeters per day. It's in the order of .07 millimeters per
day, which is--I think we can all agree is really small.
So,
essentially we have differences of--for males, it was 3 grams per day and for
females, it was 2 grams per day.
DR.
STALLINGS: There was a gender
difference in the second interval.
DR.
FRONGILLO: Right. Okay.
So, that was for the Iowa data.
So,
basically no difference in the early period and some difference, 2 to 3 grams
per day, in weight for the second period.
The
data in Newfoundland--those data--I actually showed some of those data in my
presentation yesterday.
There
were data on breast-fed infants and then three different formulas. So, I averaged together all the data from
the formulas, so we can just have two groups.
And
there, it was zero to two months, two to four months, four to six months.
There
there's a different pattern, because in the zero to two months, the breast-fed
infants for both males and females grew about 3 grams per day faster from zero
to two months, and then, after that, from two to four months, for both males
and females, there was a difference in the other direction, a large difference
in the other direction.
For
males, it was about 6 grams per day, and for females, it was about 3 1/2 grams
per day, and then, similarly, the growth rates are all slowing, but there's
similar differences from four to six months.
So,
basically, in the Iowa, there was no difference in the early period and a
difference afterwards in favor of formula feeding, but in the other data, the
Newfoundland data, the breast-fed infants grew faster in the first two months
and then more slowly after that.
DR.
GARZA: In the Icelander data, what
years were these infants fed? Do these
come from formulas fed in the '80s or formulas fed in--the Iowa data, I assume,
were formulas in the '70s, Dr. Fomon?
DR.
FOMON: They went from 1968 to 1987.
DR.
GARZA: With the predominance being
about equally spread throughout that period?
DR.
FOMON: I don't know. There's no difference between the earlier
and the later.
DR.
GARZA: Dr. Sigman-Grant.
DR.
SIGMAN-GRANT: I didn't catch the
differences in the four to six months.
Same direction as the two to four months?
DR.
FRONGILLO: In both data sets, in the
later period--so, in four to six months for the Roach data--there was--the
growth rates were faster for the formula-fed.
The
difference wasn't as great as from two to four months, but that's partly, I
think, the rates are just overall lower.
DR.
GARZA: Any other questions?
Part
of the difficulty that we will face as we go on to the next questions is that,
as we look at these growth differences, that there are other physiological
differences between these groups that are difficult at least for me to
interpret in that when studies had looked--compared breast- and formula-fed
infants, there are differences in basal metabolic rate, for example, between
the two groups before even differences in growth rates up here.
There
are differences in heart rate, in temperature regulation, energy regulation.
So,
there seem to be some concrete physiological differences that go along with the
differences in growth that need to be borne in mind, so that whether or not one
pattern is consistent with those physiological differences, whether they're
adaptive or not, makes the interpretation of this data particularly vexing at
times.
Are
there any other questions that you all have to any of the presenters?
DR.
BAKER: I'm just thinking about
this. We've heard that a formula
wouldn't be introduced unless it was going to be better. We don't know what better is.
We've
also established that our best shot at what adequate is is growth. That sort of sums up the adequacy of a
formula or breast-feeding, for that matter.
And
then we're also saying we don't know what the right growth is, and certainly we
don't want babies to grow any faster than formula-fed babies are now, maybe a
little slower, but we've sort of gotten ourselves in a circle here, because in
order to show better, you've got to measure growth, and growth, you don't know
whether it's supposed to be up or down.
So,
we can't prove that it's better. All we
can prove is that it's the same.
DR.
GARZA: That's been the view of some of
the presenters. They don't necessarily
have to be yours.
With
that challenge from Dr. Baker, let's move on, then.
The
sense I had from yesterday's discussion is that, if we look at question 4A in
the abstract in terms of distinguishing values and merits of each type of
reference, that there was a very clear preference that the default option ought
to be concurrent controls unless otherwise justified, that if one could justify
the--not running concurrent controls, that, in fact, one could move to
reference data such as either the Iowa or the CDC, NHANES, etcetera, reference
data that were pretty much in the public domain, so to speak, and that only
under unusual circumstances would one rely on historical data.
That
was pretty much true for term infants.
For
pre-term infants, the group felt that concurrent controls were necessary. We didn't see a way that one could rely on
either reference data or historical controls because of the dynamic nature of
the treatment of these infants and the center differences that exist.
Is
that pretty much where we left the discussion?
So,
if we move from there to B, which says these reference groups are based
upon--please rank these reference groups based upon the ability of the
respective control population to contribute to an assessment of normal physical
growth in the population intended to consume the formula.
And
the reason why it moves us away from the abstract is that now we're dealing
with that phrase that I was pressing the group we just heard from, and earlier
groups, in terms of normal physical growth and whether, in fact, in assessing
the normality of that growth, how one would do that with concurrent controls
and what is that concurrent control, and we will be coming to some of that in
question 6.
If
you use a reference, category number two, you're faced with the same question
which Dr. Baker introduced for us a little bit earlier, and if you move to
historical controls, I think that's possibly the easiest, because we can pretty
much, I think, from the discussion we had, say, well, that's not going to give
you much help given the nature of the way we define historical controls for
purposes of this discussion.
Who
would like to tackle B? How would you
rank these in their ability to contribute to an assessment of normal physical
growth? What would be your concurrent
controls?
Any
takers?
DR.
HEUBI: I don't think that we've
actually--independent of this issue that we can't define normal physical
growth, which is a real problem here.
I
think we still are saddled with concurrent controls and longitudinal reference
data, sort of in that order, and historical controls somewhere down the line.
I
don't think we've changed--even if you change the verbiage of where you put
exactly what you're comparing it to and knowing that this is impossible for us
to know what normal really is, I think that's where we are.
DR.
GARZA: I'd like to challenge the group.
Is
that really impossible to discuss? Can
it be true that we're in the 21st century and have to turn to an agency like
FDA and say, gee, a group of experts can't decide what normal physical growth
is?
That
is a terribly telling comment on pediatrics if it's correct.
DR.
STALLINGS: I guess I'm prepared to take
Dr. Garza's challenge.
I
think we have to make a recommendation.
That doesn't say that that will be the same recommendation in 10 years
when, you know, this will need to be done again, but I think, from the
pediatric point of view, from a child health and child advocacy point of view,
for the purposes of the exercise, that a healthy child born to a healthy mother
exclusively breast-fed for the first four months is our best guess today of
what normal growth should be.
I'll
put that out for discussion, in term babies.
DR.
GARZA: So, in your mind, a concurrent
control would be that, that in fact one would have to run a group of breast-fed
infants as concurrently with whatever you were doing and then make judgements
based on those comparison.
DR.
STALLINGS: Well, it's interesting, I
think, in my homework last night that you sent me home to do, that that became
apparent, because I changed something of my theory that I would actually be
interested in knowing how it performed against the current formula, but I also
wanted to know how it performed against breast-feeding, breast-fed, healthy
breast-fed babies.
So,
I think we're entering a time when that may be, in fact, true. I look forward to seeing the WHO data and
for us to learn about that, but knowing--you know, knowing the process, that
won't have any real-life impact certainly for a regulatory agency until that growth
grid is out and we've all had a little bit of time to use it, and you know, the
whole implementation, education, assimilation process that goes with such a
major change and approach.
So,
I think we've got to do something between now and then, and we may want to go
back to our experts to ask, if we ask the question differently, what is the
best set of data that we have for breast-fed infants in the U.S. currently
existing or combinable or whatever, could we end up with something that would
be a relatively robust reference, not a standard, but I don't know the answer
to that, and that might be one of the challenges if this committee or other
committees works.
But
I think we have to take the leap and go with the breast-fed baby as the model
for normal growth.
DR.
GARZA: Let me ask you two questions,
Virginia.
Number
one, would you then suggest to the group that, in fact, we need to have two
concurrent controls--one would be whatever formula plus a second group--or
that, in fact, you might use the sort of reference that you just described for
the comparison or the comparator for the breast-fed group, and would an interim
use of, for example, the WHO breast-fed data set that Ed described that led to
the current reference and has about 200, 300 children in it from North America
and north Scandinavia or a Scandinavian country--would that be a sufficient
reference?
DR.
STALLINGS: I would be willing to
consider it.
I
think what I would ask is for us to have access to the data and be walked
through it, you know, in a responsible way, because it's not at a peer review
stage yet.
DR.
GARZA: Well, it's been published both
in the Journal of Pediatrics and in the--and there is a whole booklet out by
WHO --
DR.
STALLINGS: Okay.
DR.
GARZA: --that's out there.
DR.
STALLINGS: So, I would certainly be
willing to consider that, but it's clear from my last comment that I'm not
fully informed.
DR.
GARZA: You would consider a reference
group rather than two concurring groups and someone would have to have three
groups in a feeding trial.
DR.
STALLINGS: Right. I would consider that.
But
what I'm interested in is us having--instead of showing the growth grids that
we have been using--historically, the '77 ones and now the 2000 one--I would be
interested in exploring having a breast-fed cohort so that we could start to
understand that.
I
mean I see this as a process, certainly both for the public health interest of
the children and for not wanting to take away an important product for babies
that need it.
So,
I'd like to learn more about that, look at the data, be walked through it.
I
don't think if we're changing formulas that we could not look at them compared
to this history of incrementally-improved formulas, which is what industry has
done.
I
just worry that with each of those steps that we've trapped ourselves into the
bigger-is-better category and that that's what we're seeing, and I think as was
suggested, you know, that it may be a fundamental regulatory change, that maybe
infant formula shouldn't be at, you know, .67 calories per cc, that that may
not--in all total, that may not be the right thing.
I
mean I don't know the answer to those things, but I think we have to be open.
DR.
GARZA: Dr. Stallings has made a
suggestion.
Dr.
Thureen, do you want to respond to that or make a different one?
DR.
THUREEN: No, I think it's the same
thing, but I want to make sure that I understand you.
The
current growth standard should be that of the breast-fed infant, exclusively
breast-fed to four months of age.
That's the standard for normal growth.
As
a separate issue, what should we use for concurrent controls? For the present time, probably a concurrent
group of formula-fed infants that doesn't have the modification that's being
studied.
Ideally,
in the future, we'd move towards the second concurrent group, that of
breast-fed infants, with looking at that as a reference standard and maybe with
using neuro-development, outcome, etcetera, but that's a process that would
occur over time, so that there would be no change in recommendation for the current
time of using concurrent controls of the same formula without the addition but
move towards, over time, having a different concurrent control group of
breast-fed infants.
Is
that what you said?
DR.
STALLINGS: I think so. This is clearly a thought--I mean this is
the part of our work that we need the dialogue for the clarity.
I
am very interested in having both--when working in isolation last night, I
actually came up with both concurrent control groups, a breast-fed contemporary
group and the primary formula and then the formula with change, when I was
looking at what would I really like to do.
So, that really is an issue.
If
we were to go that way, if we use the breast-fed baby as the only concurrent
control group, we know we're going to open up gaps immediately, because the
growth patterns aren't the same.
So,
I don't have a good idea how to walk through that part.
So,
there really are two questions. Is the
new formula as good or better as the old formula, which is usually our
question, and then, secondly, how does it compare with breast-feeding?
The
challenge that I don't know yet is can we create a reference set that performs
well enough that we wouldn't have to have a concurrent breast-feeding group.
So,
I really offer this to begin the discussions.
I'm very interested in other people's thoughts.
I
do feel strongly about--that as much as we--and I know everybody in this room
would want to do this, certainly protect children from unnecessary studies, I
think as pediatric health advocates we also need to affirm that sometimes we do
need to do studies in children and not be afraid to do the right ones. It's the balance.
So,
I'm not afraid of doing more studies on more children to get the right answers.
DR.
GARZA: Let me ask the group and possibly
our presenters to also comment on this, those that presented yesterday.
It's
my sense, as I look at the literature, that if one looks at the growth patterns
of breast-fed infants, either historically--I looked at data back as early as
the early 1900s and it's very sparse, but there's some there--and
cross-culturally, looking at children, for example, in such places like
Bangladesh to Norway, the pattern of growth is remarkably similar.
They
start off at different places, obviously, so that, in fact, the children at
Bangladesh may start off at minus-3, but if you plot their growth--minus-3
standard deviation--if you plot their growth against the WHO breast-fed data
set that Ed showed us yesterday, parallels it pretty--I mean just phenomenally
well.
If
you look at Norwegian infants, again they're much bigger at birth, they
parallel it pretty well.
Has
that been everyone's experience, and if true, would studying a concurrent
group--would that sort of consistency make as much sense, or has it not been
your experience so that, in fact, one would need a concurrent group to try to
be able to overcome the sorts of biases that reference data might
unintentionally create for us?
DR.
STALLINGS: I'll make one comment to
that, and then, really, I'm very interested in my colleagues' opinions.
I
think, in North America, practitioners have been often frightened by the
fall-off of breast-fed kids compared to our growth grids. So, the truth is I'm not sure many of us
have really looked at that as carefully or might be able to express personal
confidence.
And
then you also--the people that you have around the room--often our jobs are to
deal with children who have failure to thrive.
So, again, you know, most of us have not been doing general pediatrics
practice where we're seeing the more run-of-the-mill issues.
But
the one thing that I am aware of, you know, certainly in personal friendship
circles and professionally, is until we really became aware of there is the
natural slowing of growth compared to the current growth grids, that a lot of
people with breast-fed babies were alarmed, and pediatricians caring for them,
thinking that we weren't doing a good job.
So,
I think in North America we've got an education piece that's really just sort
of getting out there, and you know, the issue of growth charts and the optimal
reference, if not standard, is something we've been missing for a long time.
DR.
GARZA: Let me turn to the group.
Dr.
Fomon?
DR.
FOMON: I'd like to make a couple of
comments that I think are of some practical significance with respect to using
the breast-fed infant as a reference.
Number
one, if we were to analyze the infant formulas on the market from 42 to 112
days, almost all of the formulas would be in non-compliance, and if we tried to
develop formulas that would allow us to match the growth of the breast-fed
baby, we would have to switch formulas at about 42 days.
It
would be the only way to do it.
You
could not go with the breast-fed babies' growth and not exceed the breast-fed
babies' growth if you stayed with the same formula after 42 days.
So,
there are some real practical considerations.
The
other thing that I think is important in using the breast-fed baby as a
reference is that most of the studies do not account for drop-outs. We account for drop-outs in formula-fed
studies, but in general, most of the breast-fed studies are breast-fed babies
who continue to be breast-fed for a certain period of time.
DR.
GARZA: Thank you.
Dr.
Clemens?
DR.
CLEMENS: I'd like to pick up on a comment
that Dr. Merritt made a little bit earlier today, and that is, if you were to
look at all the data that the industry has collected, they, in fact, would have
more data on breast-fed infants in this country than WHO has collected in
total, and so, if you were to use that as a standard--and to go back to what
Dr. Denne said yesterday--what is the agency going to do with those data if you
don't match those particular patterns?
DR.
BAKER: I've got a question. If you were to try to duplicate the growth
of a breast-fed baby with your formula, then you would almost necessarily have
to change the whole character of the feeding trial.
It
would no longer be a growth study. You
would have to include lots of things, because you're not really interested in
growth at that point. What you're
really interested in is the formula supplying everything it needs.
So,
you'd have to look at metabolic things, at neuro-development things, at bone
accretion. You'd have to blow it open
to a full study, a metabolic study, in order to do that.
DR.
GARZA: Let me ask the group, because
that thought was crossing my mind, as well, that the assumption that, in fact,
one can look at growth in isolation of anything else fails as you try--at least
it failed in my mind as I tried to go through it, because in fact, one would
have to look at the composition of the formula.
One
would have to look at some baseline metabolic responses, because if not, one
could very easily get into a false sense of either security or insecurity by
relying on any single measure for adequacy, one for which we appreciate there
is some plasticity.
I
can give you a recipe for a small baby.
We do it in most of the world quite successfully. I can also give you a recipe for a big baby
and big children. We have been doing
that just as successfully for the last 15 years in this country.
So
that in isolation of intake data and isolation of metabolic data, one can
decide what the baseline of that information may be, but what seems to be
coming out of our discussion is that, yes, you may want more than one growth
comparison, as the way Dr. Stallings described, but that those comparisons have
to be interpreted in the light of additional data than just growth alone,
because of that plasticity.
Is
that a fair assessment of how the discussion is going, or is that unfairly
characterizing the deliberation?
Dr.
Denne?
DR.
DENNE: If I could just maybe digress a
bit, I think we're talking about or at least dancing around trying to develop a
formula that makes formula-fed babies grow like breast-fed babies, and to me
that's a hypothesis that needs to be tested.
I
mean what we know is that formula-fed babies growing like formula-fed babies do
well, and they do well in the infancy period, and as far as we know, all the
way through adulthood.
Adjusting
our standards to make a formula so that we match the pattern of growth of
formula-fed babies and breast-fed babies assumes that we'll get a similar or
better outcome, and we have no basis to make that recommendation.
It's
an interesting concept, but in the absence of any information like that, I
would be reluctant to change that standard.
DR.
GARZA: Let me be the devil's advocate
for just a bit.
Is
there any other circumstance in medicine where a significant deviation from
perceived normal physiology would be interpreted by default as acceptable
without proving that, in fact, there were no problems, where the absence of
information is sufficient, rather than the presence of information?
DR.
DENNE: I think if we were starting
today and all we had was breast-fed babies and we needed to construct a
formula, then trying to match the pattern of breast-fed growth would be an
appropriate way to go.
However,
we have, you know, 50 years of formula experience that actually is
reasonably--with reasonable good outcomes, again all the way to adulthood.
So,
given the fact that we have that experience, it's difficult to radically change
the formula in order to just match a pattern of growth, which is really all
we're talking about here.
DR.
GARZA: What I was trying to get us to
is to the point--maybe we don't have to match it but at least be able to
explain deviations from it.
DR.
DENNE: I think it's certainly
reasonable to compare formula-fed babies with breast-fed babies. I mean I think that's a reasonable thing to
do in some sort of academic abstract way so that we know what those differences
are.
But
to act on those differences, I think, is where I'm less convinced.
DR.
GARZA: So, your suggestion would be
what?
DR.
DENNE: I guess I'm suggesting that,
given the fact that we have good data on formula-fed babies and the growth of
formula-fed babies over many years, that that is a reasonable approach to match
changes in formulas to, rather than a standard of breast-fed.
DR.
GARZA: What match would you make, then,
to a--what would be the concurrent control?
Would it be the Fels data that has some formula-fed infants? Would it be a historical? Would it be the NCHS, CDC?
What
formula would we use as a standard to get that normal growth definition?
DR.
DENNE: I guess I would use some
combination of a longitudinal study, Iowa, Fels data, formula-fed infants,
probably as a primary source, and probably the CDC as a second source, which
obviously is a mixture, and we understand that.
DR.
GARZA: And that would be sufficient
without the concurrent control?
DR.
DENNE: No, that's with the concurrent
controls. I don't think this, by any
means, replaces the need for concurrent controls.
DR.
GARZA: Dr. Clemens?
DR.
CLEMENS: It's interesting to note that
even Dr. Fomon, just moments ago, made a comment relative to the duration of
kids that were on the--in his studies, and as you look at the data that were
collected in the '70s or late '60s through the data that were collected to the
mid-'80s, Dr. Fomon, if I recall what you said correctly, that both kids did
not differ.
That's
true if you look at the data that were collected in Iowa. You could look at the data that were
collected and presented and analyzed through the CDC.
Fundamentally,
those kids do not differ, that if you look at the historical data that the
industry has generated in over 6,000 kids, all those controls, concurrent
controls, mind you, that fundamentally, those kids do not differ.
LSRO
did a report just a few years and examined the nutritional requirements for
kids, and if you look at those requirements, that's exactly where the industry
is today.
DR.
GARZA: Dr. Clemens, then explain to us
the differences between the Iowa data and the Roche New Foundland data, because
those two differed fundamentally in growth pattern, both on formula.
DR.
CLEMENS: I can't explain that at this
time.
DR.
GARZA: I think it's difficult to say
that these patterns have not varied, because that statement, I think, is
difficult to uphold.
DR.
STALLINGS: It sounds like, though,
there may be another source of data that we haven't had the opportunity to see,
that if industry were able to provide the primary data on the breast-fed
infants, you know, and the sites, the geography, the males, females, that we
might have another set of breast-fed babies collected under conditions that are
common to current infant formula studies.
I'd
be very interested in seeing that, and I think what we're headed towards is
really what the FDA is prepared to do at this point is--I mean some of this is
new analysis. I doubt all of the major
companies have ever combined their data.
DR.
GARZA: Dr. Stallings, how would you
deal with the problem that Dr. Fomon raised, which is a very fair criticism of
most breast-fed data sets that I know of, and that is that, in fact, you get
terrible attrition rates, and you have a distillation that gets progressively
worse.
There's
only one study that I am aware of that is following all children, regardless of
whether they adhere to recommendations.
That was the description that Ed gave us of that WHO study, where
they're following all children to try to see whether there are differences
between those that quit at three months, four months, five months, six months.
DR.
STALLINGS: And I think that will be an
important issue. I mean I would love to
see--I mean it seems a little silly at this point to start another major
breast-feeding study to answer those questions in the U.S. or in North America
when we're going to have really wonderful data soon.
But
that is an important question, because we know what it's going to do, is add to
the variability that is artificially low in the breast-fed studies now, because
it's just the compliance-committed families.
So,
I mean but these are some of the kinds of things that if--you know, if we got
great briefing books on those kinds of things, I think the way we should head
would become apparent.
DR.
GARZA: There are some studies in the
literature that I'm aware of that have had 3-percent attrition rates for the
first four months. I mean, so they do
exist.
DR.
STALLINGS: Right. So, I think that's incumbent upon us, if we
want to consider going down this road, is to really look at that, because it's
not something that's been done, and then to be able to start to look at what--I
mean we may end up with very different sample sizes, requirements, and things
like that. It may not be as
overwhelmingly impossible as it feels, you know, as we're going through some of
this, and to focus on those first four months or maybe the first six months.
But
I also, you know, agree with Dr. Fomon that one of the challenges as we go
through this is--I mean what we now know is the nutritional needs of a baby
during the first two months are different than the nutritional needs after
that, and the beauty of it is the breast milk supply and composition changes
with that and a little bit more than we can change a commercial product.
So,
then the challenge is what are the windows that we'd need the product to have
to perform well on zero to two and two to four or two to six?
So,
it's, you know, a lot of things that might come out of this set of questions.
DR.
GARZA: Okay.
Dr.
Sigman-Grant?
DR.
SIGMAN-GRANT: Just to divert the
conversation just a little bit, if we look into the future at the possible
ingredients that might be added to formula, we talk about the nutritional
needs, and it seems that because breast-fed and formula-fed infants do grow and
thrive, that the nutritional needs are met.
Yet,
we've been hinting upon the metabolic changes or differences that might exist,
which may or may not be reflected by growth, but if some of the newer
ingredients that might be added to formula may be added because of presence,
say, in breast milk, because breast milk is the standard, does that put a
different light and sort of support the need for a concurrent breast-fed group
in the study, because that might be what might be coming down in the future,
some of those bio-active or other growth substances that are in breast milk.
I
mean we're trying to set some standards for the future.
DR.
GARZA: All right.
I
think my read is that we've come to some agreement on 4. Let me see if I'm not being overly
optimistic.
We've
summarized part A, so we can leave that alone.
In
terms of B, the group still feels that, in fact, longitudinal concurrent
controls of a formula plus--minus whatever is being tested is going to be
needed under most circumstances, that we recognize there may be some--I think
it was Dr. Baker that described it.
For
example, if you're doing a series of studies very close to each other, that
they're variations on the same theme, but in fact, one might be able to rely on
one concurrent control group for multiple studies, that it's foreseeable that
that would work, that, in fact, there should be a comparison in addition to
that with some reference source for the breast-fed infant to try to understand
what those deviations are from that growth, that there may be instances of the
type that Dr. Sigman-Grant described where you may want to run a concurrent
control but that we don't envision that necessarily being always the case, but
at the very least that there ought be some reference data set that one ought to
be able to make that second comparison with the breast-fed population and to be
able to identify reasons for the deviation, that in fact it may be expected
based on historical growth patterns from other formulas that this is not
unusual or that, in fact, it was to be expected because of the nature of the
change, but that there ought to be some explanatory information that comes
along with that comparison, but that generally, then, we would keep the ranking
pretty much the way we described for A, that these would be used to assess
normal growth in the way that I've just described, and so that we've done C in
terms of defining the role of that reference group, as well.
So,
is that a reasonable summary of 4? All
right. Then, if it is, let's take a
short break of five minutes to get your coffee, bring it back to the table. I have to ask you to bring it back, because
we've got to go through 5, 6, and 7, and we may not make it, folks.
[Recess.]
DR.
GARZA: All right. So, we're going to go on to number 5, and
that's asking us two questions.
For
the purpose of evaluating normal physical growth--that's our favorite phrase
again--of infants new formulas, what criteria should appropriate infant growth
reference groups meet, each or selectively, in terms of feeding history,
gestational age at birth, sex, racial background, socio-economic status,
etcetera, in comparison to the experimental or study population, as opposed to
perhaps the reference, and in comparison to the population intended to consume
the formula?
I
thought the second was surprising, but not so when you stop to think that, at
our last meeting, we discussed the fact that term infants, for example, might
be used--term data might be used to justify pre-term feeding, and so, that
didn't seem so--such a disconnect once I thought about that.
So,
in comparison, then, I guess, what similarities exist between the study and the
control populations, is the way I interpret the first bullet, or a reference
group, if you're using one, or a historical group, if you're using a historical
group.
Now,
we might wish to differentiate. For
example, if you're doing a concurrent control, then obviously the idea would be
a randomized, so that they're going to be the same if you randomly assign them.
That
would be the intention of that design, at any rate.
Once
one gets away from that, then there are criteria that you would have to think
about in making that match, because you're no longer dealing with a randomized
assignment.
So,
I think the first one is easy, unless anyone would take exception to that.
Moving
past that easy one, then I'll turn to the group and ask you to address the
difficult one.
DR.
ANDERSON: I think we want to
re-emphasize how important we think it is that, in settings where a comparison
is thought required, that it ought to be done through a randomized trial.
Having
said that--and as I think our recommendations from the last meeting implied,
the randomized trial ought to be done optimally in the population designed to
consume the formula, or there ought to be a compelling argument that the answer
that one gets in a different population is the same as one that one would have
gotten if one had done it in the population intended to consume the formula.
I
mean after that, I think the--any other approach is sub-optimal but that the
focus ought to be on the kinds of characteristics that we recognize from both
randomized and follow-up studies predict for the type of pattern of growth that
one observes.
So,
from the discussions here, it seems clear that gestational age at birth has a
major impact, and to the extent that there are other factors that are readily
measured that are known to be strong predictors, that it would be incumbent on
those submitting such information to be able to demonstrate that the results
that are observed, either--for instance, if they were largely similar, that the
similarities are not as a result of underlying differences and predictors of
growth that, if they were adjusted for, would lead to very different observed
growth patterns.
DR.
GARZA: Based on what we've heard, then,
one would definitely want to see a match on sex, because of differences between
boys and girls.
One
would want to see a match on gestational age, for reasons that we've discussed.
Health--general
health standards would be a third that we talked about, that you couldn't
necessarily extrapolate from one healthy population to unhealthy populations,
or conversely, and we had detailed discussions of that point at the last
meeting.
Less
clear are feeding history. For example,
if, in fact, one was comparing two formulas and one formula group was fed human
milk or some other formula in the early period to a greater degree than the
concurrent or comparator group, would that present a problem?
I
mean how closely do you want--do you think that one ought to look for a match
with feeding history? I mean that's
something that has come up.
In
terms of racial background, it's tough for me to make a point for that one.
Socio-economic
status--tough for me to make a point on that one either. I mean all kids ought to grow--I'll use the
phrase "normally," whether they're rich or poor. In a society such as ours, I don't see that
that's relevant, necessarily.
DR.
SIGMAN-GRANT: The feeding history--you
just mentioned formula or breast-fed, but I would think you would want to match
on introduction of solids and other weaning and complementary foods, because we
haven't talked about that, but some of the data from some of the years,
complementary foods were introduced very, very early, and that may have been
different for breast-fed and formula-fed babies.
So,
I think you would want that in the study.
DR.
GARZA: Complementary feeding history?
Other
matches?
DR.
DOWNER: I was thinking about
socio-economic on the grounds that, if you don't have money to purchase formula
and you're not breast-feeding, that will definitely impact.
I
understand that the goal is, regardless of your socio-economic status, to make
sure that you have the best outcome possible, but if we're looking at matching,
I think that is very important to look at.
DR.
GARZA: Okay. I was working under the assumption that, if you were doing a
growth study, then those factors in terms of accessibility would be controlled. Perhaps that's too much of an assumption.
Do
you feel that SES matches would be necessary, Dr. Heubi?
DR.
HEUBI: That wasn't what I was going to
comment on.
DR.
GARZA: All right. Well, let's get done with this one, then, on
SES.
DR.
HEUBI: I will comment on it.
I
do think it's probably important to match as much as we possibly can on SES,
although I sense that, after having participated in some of these trials, that
we're basically doing that in general, because in most cases, you're excluding
children who are in the WIC programs because there's no real incentive for them
to participate in these studies.
DR.
GARZA: What is the biological proxy
that we're using or what is the proxy for SES, then, because I'm trying to
understand the biological reason why you'd want to control for SES if you're
doing a growth comparison between two formulas.
Kids
that are poor don't inherently grow slower.
I mean they grow slower because they don't get food.
DR.
HEUBI: I'll tell you what my
first-blush response to that is, is that there are so many other extenuating
circumstances in those households that may somehow impair their growth and may
not make them --
DR.
GARZA: Dr. Clemens?
DR.
CLEMENS: Actually, demographically, in
the control, as well as in the study population groups, the intent for the
industry is to be absolutely identical, and that's indicated in the protocol,
including the SES.
Breast-fed
kids are self-select, so it's difficult to match SES, and it's difficult to
match some of the other parameters.
It's difficult to match the in-house situations as well, as you probably
have experienced.
DR.
GARZA: All right. So, one would then look at SES but look at
particular variables, I would imagine, like maternal education, birth weight,
all the various things that you think would be impacted to make sure that, in
fact--that's the sense of the group.
DR.
CLEMENS: That's correct. We do that already. That's indicated in the protocol.
DR.
GARZA: Dr. Heubi?
DR.
HEUBI: I think it's probably not
totally appropriate to be over prescriptive about what their antecedent
breast-feeding or formula history was before they are enrolled.
It
depends upon when you want them to be enrolled for the beginning of the trial
that would determine whether you would restrict what their previous feeding
history was, and that's a piece that I don't think we've really addressed.
I
know there's been discussion about trying to enroll age 14 days, and Dr. Fomon
talked about at age 28 days, and I think that's a piece that ends up being
fairly important, about when you enroll your subjects in terms of what their
antecedent feeding history truly is.
Certainly
in the circumstance where you were studying a soy formula, you wouldn't suggest
that they be switched from a cow's milk-based formula to soy, and similarly,
you wouldn't suggest that a breast-fed baby would be switched to formula to
participate in the study.
DR.
GARZA: So, how do we deal with--what is
the match between feeding history--it would just be dependent upon the nature
of the study, so it's very difficult for the group to make a generic comment,
other than that you ought to think about it.
Is that what the group is saying?
DR.
STALLINGS: Not to directly answer that,
but I think one of the groups that we have--often, many of our studies are
designed to keep people exclusively formula-fed or exclusively breast-fed when,
in fact, in practice, the third group, the mixed feeding children, are really
very common.
So,
I just bring that up as--that's something that I think we need to incorporate,
because that really--when you talk about the environment that you're really
going to use the formulas, as we get more and more successful for
breast-feeding for the first number of weeks or months or however, the other
type of complementary feeding, when you need the formulas to continue that
cycle. So, I just wanted to bring that
out, and in fact, that was part of the discussion at break.
I
think it's beyond what we can do in this setting to really keep detailed
history of complementary feeding.
We
might be able to say first initiation, because it just gives you a time point,
and I think that's probably accurate, but--so, my sense is I really would not
deal much with complementary feeding, other than maybe record it.
The
feeding history, I think, will be a moot point, because I think we're going to
need to enroll them by eight days or 14 days, and then the rest really goes
from the protocol inclusion or exclusion criteria.
DR.
GARZA: Dr. Sigman-Grant, do you want to
comment to that?
DR.
SIGMAN-GRANT: From the practical
standpoint, I really think you need to account for complementary feeding.
It's
so variable. If you're not in a
hospital setting, the time of introduction of cereal varies from--even
now--from a couple of weeks to six months.
So,
it's so variable, I think you at least have to account for it, maybe not
measure it but certainly account for it.
DR.
GARZA: You would agree that the only
thing that you see as critical is the age at introduction, not necessarily
keeping--or collecting additional information for the amount of complementary
feeding that occurs, how frequent it is, whether it increases over the time of
the study, but if you knew, gee, they started at one month or two months or
four months, that would be sufficient, because I think that's what Dr.
Stallings said, that it's the age of introduction. Beyond that, it really gets to be impractical.
DR.
SIGMAN-GRANT: If you want a true
picture of growth, I think you need to look at the progression. So, someone who starts complementary feeding
early tends to progress, so the child gets more and more and more, and that
might impact the growth study and how much actual formula they're consuming.
DR.
CLEMENS: Actually, if you look at the
protocol, first of all, on enrollment, we do examine whether breast-fed or
formula-fed, they're not to be exclusively formula-fed, because we do note
there is a difference at that point.
Secondly,
all complementary feeds are, in fact, monitored on a regular basis. There is part of the form to examine all of
that issue, and it's part of the compliance.
If,
in the estimation of the investigators at hand or the research investigators,
in fact, that the complementary feeds are out of bounds, for whatever reason,
then, in fact, those individuals are out of compliance and discontinued.
DR.
GARZA: So, you're suggesting that ought
to be made mandatory, that the FDA ought to require that information, rather
than just receive it, because it's supplied.
DR.
CLEMENS: We already provide the
information. In general, the industry
provides that kind of information.
DR.
GARZA: But you think it ought to be
required that everybody supply that information. Is that what you're saying?
DR.
CLEMENS: We can work with that.
DR.
GARZA: The reason I'm asking is, if
there is a new manufacturer that's not part of the Infant Formula Council and
they choose not to, right now there's nothing that requires it.
DR.
CLEMENS: That's right. That's not required.
DR.
GARZA: And I was asking whether you
felt it should be required.
DR.
CLEMENS: It should be required, and we
do provide those kinds of data.
DR.
GARZA: Okay.
Any
other comments on that?
[No
response.]
DR.
GARZA: All right.
So,
in comparison to the population intended to consume the formula, how much of a
match should there be between your test population--the example that we've
dealt with in the past is, can you study term infants and then make inferences
to pre-term?
Are
there other instances where you think that, in fact, if it's studied, for
example, in six-to-12-month-old children, should it be used at one to six
months?
We
had some discussion as to how the nutritional requirements were quite different
between infants the first three months and the last three months of infancy.
So,
that's another example, I think, that we heard about where there should be a
match between the study population and the population for whom the formula is
intended.
Obviously,
boys and girls, because it's intended to feed both sexes.
Those
are the easy ones.
Are
there other matches that you feel ought to be made?
DR.
DOWNER: Also mention the gestational
age.
DR.
GARZA: Okay.
DR.
DOWNER: And general health.
DR.
GARZA: All right.
DR.
BAKER: I would say that this--if I'm
reading this question right, it's driven by science, and you match you control
group to your trial group as closely as possible, and if you want to make
inferences on some other group, that's up to you to prove that that's okay, but
you don't match your control group to some other group.
DR.
GARZA: It has to do with a study group,
I think.
As
I'm reading the question, they're asking, if you set up a study group, how
closely does that study group have to conform to the intended population, so
that the external validity issue is the issue that they're getting at? I think that's an external validity issue.
DR.
DENNE: I just was going to say I think,
you know, at least in some sense, this ought to reflect the population of the
United States and that, although that's probably impossible in a relatively
small study, it shouldn't exclusively focus on a specific socio-economic
group. It shouldn't specifically
exclude--explicitly just be white or black.
It should be relatively representative.
At
least that's the way I read the intent of the question.
DR.
GARZA: Dr. Kuzminski?
MR.
KUZMINSKI: My logic takes me just to a
very brief answer, and the answer it is very closely, because under the
criteria, I would have to defer to the medical expertise, but if the change is
being contemplated against an existing formula that's out there in the
marketplace and I would think a manufacturer would want to know how that change
is going to affect the market for that existing product.
So,
whatever medical parameters can be put into the study design are the
appropriate ones, they should be included, but in terms of the context of the
question, how closely should the population intended to consume the formula be
represented in the study, I think very closely.
DR.
GARZA: I think that's the sense. I don't think I could summarize the sense of
the group any better.
And
before I forget, Dr. Kuzminski and I had a discussion during the break, and I
want to make sure that--I thought we weren't in disagreement and that we had
not shut the door on the use of historical controls or term infant studies in
question 4.
We
listed it last but recognize that there would be instances where that would be
appropriate but that that would have to be justified, that in fact, because it
was the lowest--the least well-received or ranked last, that, in fact, it
couldn't be used without some justification and that we didn't see that case
with pre-terms but with term infants that that might be possible.
Dr.
Anderson?
DR.
ANDERSON: I think relative to the
present question, to the extent that the study population differed from the
population that intended to consume the formula, it would be incumbent on the
manufacturer to demonstrate that there was no reason to suggest that the
findings of the study could not be directly applied to the population for which
the formula was intended.
DR.
GARZA: So, you'd like them to address
the external validity of their data.
Okay. Well, we've dealt with 5.
Dr.
Heubi?
DR.
HEUBI: Just as a point of
clarification, does the FDA require the same kind of demographics as the other
PHS agencies for clinical trials?
Do
they require Hispanics and African-Americans?
DR.
GARZA: The answer was no, since the
record shows the staff shaking their head, and obviously, the sense of the
committee was that, in fact, those groups ought to be representative in the
sense that Dr. Denne described. I
didn't hear any objections to that.
It's
an important point. I think not many of
us have been involved in trials.
I
remember being involved in one trial where we were told that they couldn't find
African-Americans, and the study was being done in Manhattan, which I thought
was amazing. I offered to give them a
tour of the city.
DR.
WALKER: You used the word
"require." I think it's
important to remember that this is a notification process, not an approval
process, and we're under very different regulations than you would be in a drug
approval process.
DR.
GARZA: Thank you for that
clarification. That's important.
DR.
HEUBI: All I can say is we're used to
being hammered with this at the NIH.
DR.
GARZA: All right. Well, let's move on to number 6, and I'm
actually more optimistic. I thought
this was going to take more time, but much of our discussion for question 4, I
think, might help us deal with this one.
So,
listed below are examples of control feedings or clinical comparators, and then
you have six bullets.
You
may have other comparators that you would like to present to the group.
We're
being asked what are the most distinguishing values and merits of each of these
types of comparisons in infant study test formula versus a comparative feeding
for assessing normal physical growth, and there again, we have that phrase of
"normal physical growth" coming back to us.
So,
you've got these six bullets. I'll read
only the first two: a current infant
formula plus a new ingredient, a current infant formula, obviously, with out
that new ingredient, and human milk.
So,
those are three groups.
We've
talked a little bit about how one might use those three groups in our
discussions of question 5.
A
second was only the first two groups that I identified, and then there are
various permutations through the six bullets which we don't have to read.
So,
who would like to tackle A? And here
again, we might want to take only those two or three that would be of most
value, perhaps have some that are moderate value, and those that you would
never suggest that anybody even consider doing.
Dr.
Anderson?
DR.
ANDERSON: Well, I'll take a shot at
this, because I think I'm likely to be somewhat controversial.
I
think that the most useful of these is the second one, which is the test
formula versus the formula without the new ingredient.
In
the context of assessing whether a new infant formula is appropriate for
marketing, I personally don't think a concurrent cohort of breast-fed infants
is relevant, although I do agree that an assessment of the growth data to some
reference may provide useful information.
There's
an issue that hasn't been discussed all that greatly here but which I want to
raise briefly, is that we've heard this morning that there's a great deal of
historical data available, and I must say that my enthusiasm about the use of
historical data would depend greatly upon what those data look like.
So,
for instance, if, of the 60 trials we heard about this morning, their observed
growth patterns for marketed formulas were all extremely similar, so that the
variation from one study to the other was minuscule, and one came with a single
cohort of individuals fed a new infant formula which tracked exactly as the
others did, my enthusiasm for that being sufficient information to conclude
that it promoted growth consistent with that seen with contemporary infant
formula would be high.
On
the other hand, if the variation from formula to formula was quite large, then
my enthusiasm for using the historical information would be diminished, and as
my enthusiasm for tests in populations which are not those intended for use is
low.
The
idea of testing infant formula plus a new ingredient so that that new
ingredient could be added to some different matrix or some different formula
would also be low.
DR.
THUREEN: The second bullet is sort of
number one in preference. Then, good
historical controls would be number two, then?
Or didn't you even go that far?
Bad historical controls would be at the bottom.
DR.
ANDERSON: If forced to rate the
options, I certainly have no objection to the collection of information from
breast-fed infants at the same time the study is conducted, but I personally
don't think that the information is terribly useful for the purpose that the
study is being conducted.
So,
having said that, the second bullet would be my first and very much favored
choice of the ones available.
DR.
GARZA: What if one were to modify the
first bullet to indicate the use of reference data of the type that we
discussed in question 5? Would that be
preferable to bullet two?
DR.
ANDERSON: Then it would come very
closely beyond bullet two, in my way of thinking.
DR.
GARZA: That would be your favored
bullet and having all three?
DR.
ANDERSON: No. Two would be first, and one would be very closely second.
DR.
GARZA: Okay.
So,
you would see the comparison with a reference of breast-fed children as being
less valuable than just the comparison between the formula and the formula plus
ingredient.
DR.
ANDERSON: Absolutely. So, three would be very much below--in fact,
I would have three probably below four and five.
DR.
GARZA: I was suggesting that the first
bullet would be modified to not having concurrent children but a reference.
DR.
ANDERSON: Right.
DR.
GARZA: And then bullet two would be
just as it is there, with children being--a breast-fed reference, I'm
sorry. And then number three would be a
concurrent infant formula plus a new ingredient with actually recruiting
breast-fed children, so that there would be a difference between bullet one and
three.
So,
with that modification, it would be bullet two that would be your favorite.
DR.
ANDERSON: If I understood what you
said, in the first line, the breast milk was meant to mean some reference, then
I personally would find one and two essentially identical.
DR.
GARZA: Okay.
DR.
ANDERSON: Three, where there was
information on infant formula plus a new ingredient and information on either a
concurrent breast-fed group or a reference would be very much less, because
there is no either randomized comparison group with the infant formula without
the new ingredient or some reference to the expectations for infant growth when
fed what's known to be appropriate infant formula, so that, to the extent that
the references and the historical data provide a clear sense of what the
expectation would be for the outcome when infants are fed an appropriately
formulated infant formula, those then would become sort of second tier from the
first and the second.
DR.
GARZA: Okay.
Dr.
Sigman-Grant?
DR.
SIGMAN-GRANT: I'll take a different
approach and go from bottom up.
Because
of the difference in formula matrix, the last one, the infant formula plus the
new ingredient, versus any of the others, I think that should probably be very
justified, because like we heard yesterday, the composition and the batching
and the process may vary amongst formula companies, and therefore, needs to be
tested within each formula.
Currently,
I think that, given the data and the status today, just having number three,
current infant formula plus a new ingredient, versus breast milk, would not be
appropriate right now, that that would not serve as a good comparison.
DR.
GARZA: Okay.
DR.
SIGMAN-GRANT: The current versus the
historical data or the current plus the new ingredient versus the reference
data--if you look at that, I think comparing it to a longitudinal historical
data would be preferable over cross-sectional.
So,
in other words, the Iowa-Fels would be preferred over, say, the CDC's.
I
have a toss-up between the first two.
I
think if you're going to have a current formula and adding a new ingredient,
you must compare it a historical--the formula without the new ingredient. You just have to. It wouldn't be appropriate not to.
I
would prefer to see a breast-fed cohort or comparison to a breast-fed reference
standard, so that somehow we can start establishing that comparison, because I
think we've gone around and around and around, and we need to at least start
addressing it.
So,
this might be a good point in time to recommend that we start collecting or
compare it to breast-fed babies.
DR.
GARZA: Is there anyone that wishes to
disagree with that general ranking? I'm
not too worried about those that we've ranked at the very end, because I don't
think we would be recommending those to FDA anyway.
Dr.
Stallings?
DR.
STALLINGS: I tried to make myself put
them into two categories to start, I mean sort of rare to no, that they
shouldn't be used, and this is recognizing that we are shifting, you know, the
concept of normal physical growth and that the work of the first day and some
of the others have been that we are concerned about both failure to thrive and
over-nutrition.
So,
my rare to no's would be the last one, would be number five, which is just the
new product versus only reference data.
It would be number four, which is sort of what would be the new product
versus other reference data, and when I did that, I also began to feel that the
number two, which is new product versus old product, with no comparison to
breast-feeding, would also be rare to no.
So,
that leaves me the number one, which is the new product, the old product, and
reference data for breast-feeding, or number three, which is the new
product--no, sorry--number three would not be good, because it doesn't contain
the old product.
So,
I really--over the process, it really is about old product, new product, and
either breast-fed babies as a concurrent or breast--an adequate breast-fed
reference, which we know we need to work on some more, but those would be the
two really viable options.
DR.
GARZA: Dr. Baker.
DR.
BAKER: I agree--I would list number one
as first, but I think it's--there is also some use in including other reference
standards besides the breast-fed baby to avoid formula drift, to make sure that
you're not going in one direction all the time.
So,
I think some other references might be appropriate, as well, and as I
understand it, that's not really that hard to do, so we're not asking a whole
lot.
DR.
GARZA: Is there a reference that you've
heard that you would recommend?
DR.
BAKER: As I understand it, I think that
the Fels data, the longitudinal data, would be preferable to the NCS data.
DR.
GARZA: Okay.
Dr.
Clemens.
DR.
CLEMENS: Thank you very much for the
opportunity to speak.
Just
to make a comment on the matrix, which we don't have any food scientists in the
group, I think Dr. Benton yesterday commented on batching--Madeleine, you made
a comment, as well--historically that you look at the worst case scenario, and
that is you look at liquid processing, usually receives the greatest amount of
thermal impact, if you will.
That
is typically the product that is used for clinical trials, to look at protein
digestibility, matrix. You could look
at available leucine, reaction products, all those kinds of things.
That
is considered, if you will, the worst case scenario.
That
is the product which we evaluate, and that is the matrix which we assess at
clinical trials.
Based
on our clinical experience, based on our food science knowledge, and based on
our own theory and understanding of food processing, food chemistry, we realize
that, when you spray-dry a product, it's not nearly as severe, so hence we do not
do clinical trials on products, some logistical things, as well.
Secondly,
I think it was Dr. Merritt this morning, as well as Dr. Vanderhoof and Dr.
Saavedra, indicated typically we will conduct clinical trials using the--if you
will--the new product, if you will, as well as the old product or the product
currently on the U.S. market.
However,
there are cases, a case-by-case situation, where we, in fact, can provide
cohort data that we don't run a concurrent control.
Also,
we have--in each case, we have data compared usually to the Fels, NCHS, or we
can, in fact, today compare it to the CDC data.
So,
all those are really quite easily done.
I
just wanted to reiterate, typically we conduct trials, current infant formula,
as well as the new product, as well as with the option of providing cohort
data, which are from clinical trials run in the past.
DR.
GARZA: Okay.
Dr.
Briley?
DR.
BRILEY: I would go with the first one
as number one, and obviously, we have to have the current infant formula with
the new ingredient, as opposed to testing against the current formula, to see
what the differences were.
I
still think, unless we get reference data on the breast cohort, we need to
start doing that, and maybe we can get it as a reference. Maybe we just have to start collecting
it. But I think we need to be looking
at that.
DR.
GARZA: But you would be willing to
accept both, either if FDA looked at a reference data set or a data set they
could use to compare breast-fed infants' growth patterns with these others,
that would be sufficient, or would you conclude that no, they have to have a
concurring group of breast-fed infants studied, in addition to the other two?
DR.
BRILEY: That's a pretty hard thing to
call in the sense that the reference data--I guess I'd want to see it to see
how well it came along and how old it was.
There
are a lot of factors in breast-feeding that we can't address here that make a
great deal of difference, and so, I'm going to opt on that one to say reference
data for now, until we see it, and then go from there to make a decision later.
If
it's good enough, then fine. If it's
not, then let's go back and get it.
DR.
GARZA: Okay.
Dr.
Thureen?
DR.
THUREEN: Well, I don't think I
fundamentally disagree from anybody. I
think that the second bullet is probably the most practical, current formula
versus new ingredient, and running a concurrent study.
If
you've got the reference data from breast milk, I think that's great. I wouldn't go out and initiate a new study
just to prove that the new formula is better compared to breast milk. So, one and two almost become equal if
you've got the data.
Close
behind that would be great historical controls. That would be number three, but it could almost equal the other
two if you had really good, nearly concurrent data, and then farther down would
be the reference group, but I don't think there's a strong indication right now
for doing a breast-fed concurrent control with a new formula.
DR.
GARZA: Dr. Denne?
DR.
DENNE: In the interests of time, I
would concur.
DR.
GARZA: Dr. Kuzminski?
MR.
KUZMINSKI: I concur exactly with Dr.
Thureen.
DR.
GARZA: Dr. Stallings?
DR.
STALLINGS: I think what Dr. Baker said
was very important, and I realized if I were sitting on the other side of the
table, I would want this information.
So,
all of the studies, I think, still would be reported compared to the CDC data,
because we're going to need to know that.
All studies would have the new ingredient formula, because that's why
we're doing it.
Then
studies would either have a concurrent old formula group or very recent, very
comparable historical data, like we did it last year, very tight, and then the
breast-feeding control group is either concurrent breast-feeding group or solid
reference data.
So,
I think there really are four components to what the regulatory agency should
be evaluating.
DR.
GARZA: One of the things that I
heard--perhaps I heard incorrectly--from Dr. Baker was that a longitudinal
component would be important.
That's
missing in the CDC. Would you prefer
the Fels, Iowa data that, in fact, at least is based on a longitudinal design,
as opposed to the CDC? Because I
thought that's what he had said.
DR.
STALLINGS: I think you're right. If it were my job to make a decision whether
it was safe or not and all of these things are really just data presentation,
then Fels, Iowa would be, really a fifth component.
Then
you would have the longitudinal data.
You would have the data that all of us see on a daily basis, what is the
growth grid that we use.
So,
then you've basically--no matter what the question was, you've got all of this
stuff in front of you, and those are not difficult things to provide. Those are just running it on a different
growth grid.
But
I think, then, that puts the regulatory agency in an opportunity to see it and
to be able to answer all the questions, and certainly industry is going to want
to know all of that anyway.
I
don't think any of this would be things that they would not have explored.
DR.
GARZA: Before I turn to Dr. Clemens, is
there any voting member that wants to modify what Virginia just said? What she's saying is she feels that having
two concurrent feeding groups, a current formula group and a current formula
plus new ingredient group, that one would then take that data and compare it to
at least three different growth patterns.
One
pattern would be the breast-fed group, wherever that data may come from, a
second pattern would be the Iowa, Fels longitudinal growth pattern, and a third
would be the CDC growth grid, but that one would want to see how growth
compared across those different reference data sets and explain deviations from
it, either positive or negative.
Dr.
Kuzminski, is that what you said?
MR.
KUZMINSKI: I think that's very
thorough, extremely thorough.
DR.
GARZA: Is that a code word for not
necessary?
MR.
KUZMINSKI: I think I anecdotally, to a
colleague here, used the term "is that overkill?"
DR.
GARZA: Dr. Briley?
DR.
BRILEY: But I would argue you would
have those data.
They're
already there. They're in the computer,
and each time you did a new formula, you would only have to compare it to that
and explain what's going on.
I
mean it's not like that you have to go back and collect it again. There would be a little bit start-up,
maybe. Maybe not. I don't know what they keep now.
DR.
BAKER: I'd agree. I don't think that's overkill.
We're
not really asking to do another study, another group. We're just asking for comparative data that's already there.
So,
it's not a--that's not a big deal, I don't believe.
DR.
GARZA: Let me ask Dr. Fomon to comment
on this discussion.
DR.
FOMON: Thank you. I know I'm not allowed to comment. I appreciate it.
I
just wanted to make the correction that everyone has been speaking on
longitudinal data about the Iowa, Fels data.
The Iowa, Fels data as presented are not relevant to this discussion. It's the Iowa data.
The
Iowa, Fels data start at birth, which are reported weights and are reported for
birth to one month, birth to two months, one month to two months, one month to
three months, and so forth. What you
need for formula comparison is eight or 14 or 28 days to some later time.
It's
the Iowa data, not the Iowa, Fels data.
DR.
GARZA: Thank you very much for that.
Dr.
Clemens?
DR.
CLEMENS: Your earlier comment--compared
to the various groups--the question, if you collect data from breast-fed kids,
how do you compare--what are the significance of those comparisons? We don't know that. I think we're much too early into that.
Maybe
this is an opportunity, frankly, to look at a research opportunity and to
explore those particular comparisons for future application. From a regulatory perspective, it seems in
what we've discussed so far, the terms concurrent controls, historical
controls, as well as the Iowa data, would seem to be quite appropriate, but I
think we're much too early in understanding the significance and comparison and
impact of breast-fed and breast milk to make that comparison from a regulatory
perspective.
DR.
GARZA: I don't think anyone suggested
that there be concurrent breast-fed data collected but that, in fact, since
everyone we heard from industry indicated they didn't know what a normal
pattern was, then, indeed, making those comparisons seems to make sense.
DR.
CLEMENS: What is the significance of
that pattern?
DR.
GARZA: If you deviate from it, I would
imagine you'd have to describe why you thought you deviated.
If,
in fact, you deviate--let's assume that you've got two formulas and one formula
deviates, it goes up or down. Is it
good or bad? From the old formula.
DR.
CLEMENS: From the old formula, it's one
thing, but deviating from breast-fed is another issue.
DR.
GARZA: What will it mean if it goes up
or down from the old formula?
DR.
CLEMENS: We can explain those
deviations. We just can't explain the
deviations we see with breast-fed kids.
DR.
GARZA: I don't know.
Is
that the sense of the group and, in fact, making that comparison makes
absolutely no sense?
Mr.
Anderson?
DR.
ANDERSON: I don't think that it makes
no sense, but I do think that the--for the purposes of this discussion, the
relevant comparisons are not to the standard, but to the extent that a new
formula differs in substantive ways from old formulas in the ways that they
deviate from breast-feeding, and so, my personal view is that these references
are useful not for the absolute comparisons but for their usefulness as a
reference to compare new formulas to old formulas.
If,
for instance--and new formula showed note differences in a prospective control
group, and yet one found differences to the standard of, say, twice the
increase in weight per day based on the breast-fed standard, then it seems to
me incumbent that that be explained in some way.
DR.
GARZA: How would you avoid formula
drift of the type we've heard is possible if the only two comparisons we make
is only with the new ingredient formula, so that you could always be drifting
in one direction without making a comparison to one or the other?
If
we just do bullet two, how do you avoid drift?
DR.
ANDERSON: That's why I thought--sorry,
I wasn't clear--that the standards would be important as a reference to which
one could compare formulas.
I
mean on that basis, you could observe drift, that curves were moving away from
the 50th percentile, for instance, or that there were substantial deviations
being observed from a breast-milk standard--sorry--reference.
DR.
GARZA: Okay.
So,
you still think that a reference--you were not in agreement with Dr. Clemens,
then, or you were? I wasn't clear. Because he thought that all you needed was
just bullet two, that doing the third was really not going to provide any
additional information, as I understood his comment.
DR.
ANDERSON: I'll let him decide whether
we're in general disagreement or agreement.
The
references are--my sense is the references are useful because they're
references and that the useful comparisons are not a formula to the reference,
because I'm not sure what that means, but a new formula to other formulas based
on using the reference, because that provides information about how a new
formula might--or a series of new formulas might deviate from where we have
been in the past or recognize that a new formula was substantially different in
some way to some reference, and in that setting, it would be incumbent to
attempt to explain what those differences were.
DR.
GARZA: Dr. Stallings?
DR.
STALLINGS: There's some interesting
potential new scenarios here.
If
we're comparing a new to an old formula, a new ingredient, and now the growth
is whatever the standard is, the 3 grams a day, 2 grams a day, now the growth
pattern that's demonstrated is actually slower or less than the old formula but
still significantly better than breast-feeding, then we may have a chance to
make a different kind of decision, which is I think the regulatory agency's
been in a position where it had to be comparable or better, and then make a
judgement decision that we actually could have formulas that are providing adequate
nutrition that don't sustain growth only at a higher level.
And
that might be an interesting way to start dealing with some of the things that
we have probably out of, you know, the last 10 or 15 product improvements.
So,
I think this--you know, I don't think it's going to be easy, but I think it
does open the possibility that we start to have--and especially with
this--we've gone with the incremental data analyses, the male/female questions,
and the, you know, early enrollments and looking at the first 42 days and that
sort of thing.
We
may actually really be able to tell things in a different way, but I think one
of the things that might happen is industry might come with a formula that they
believe is completely adequate from its composition and from its manufacturing
and it shows growth patterns somewhere the old product and breast-feeding.
And
with that, you know--and again, remembering this isn't pre-approval in the
sense of a drug, that they could say, well, you know, we think we're still right
on the nose, that this is a good product for all the background physical
chemistry and food science and nutrient content and bio-availability, we think
we've got a good product, and because it doesn't make it grow better than the
last one, we are still interested in marketing it, because we think we're where
we want to be.
So,
I just wanted to bring that up. When we
make it a two-tail test, I mean there are some things that even in the
inadequate growth, if we have had product drift over the last 10 or 15 years,
this might be an opportunity to start to understand that and potential next
steps.
DR.
GARZA: We now have three different
scenarios.
One
is that, in fact, we have a comparison of the two formulas plus the three
references we described--the CDC, the Iowa, and the WHO breast-fed data set,
for example, as a breast-fed group--a second that says no, that really is
overkill, let's just do the two formula groups and one of those three but not
necessarily all three, and--well, possibly two more--a third that says no,
let's just do the two formula groups and a non-breast-fed reference, because we
really don't know much about what breast-feeding will tell you, or a fourth
that says no, let's just compare the two formula groups, because that's really what--where
our interest lies, just in that comparison, as the top.
Now,
that doesn't discount that you might want to do any of the other three, but in
terms of a recommendation that that's all that we would see as absolutely
essential.
Now,
I think I identified all four positions.
Let
me go around the room and try to get a sense of which among those four--and
I'll say them again.
I'll
just use the code "two formulas," and we'll know what that means, all
right?
Two
formulas plus three references--and you all know what the three references are.
The
second is two formulas plus only a non-breast-fed reference.
The
third is two formulas plus only a breast-fed reference.
And
the fourth is only two formulas.
Now,
notice that I left out two formulas plus a concurrent breast-feeding
group. That was also discussed, but I
didn't hear much enthusiasm for saying let's get it on the table. If people want to do it, we wouldn't object,
but those were the four that most individuals spoke to.
So,
let me go around and ask you to identify your top two choices and see if we can
get a consensus from that as to which one would be--whether we could agree on
one.
Who
wants to start?
DR.
MOYER-MILEUR: I think that since the
data is available, I am most comfortable with number one and then would accept
number three, as well, and again, number two makes me nervous because of the
potential for drift by constantly comparing formula against formula and
not--and I guess I just need to make this comment, that if formula manufacturers
are using breast milk as their model, then why would not the growth of an
exclusively breast-fed infant be your standard? I guess I'm confused as a clinician.
DR.
GARZA: I think that's a rhetorical
question.
Dr.
Sigman-Grant?
DR.
SIGMAN-GRANT: Ditto. How's that?
DR.
GARZA: Very nice. One and three, with one being your top
choice.
DR.
SIGMAN-GRANT: Yes. And I would exclude four.
DR.
GARZA: And you would exclude four. All right.
DR.
DOWNER: I think research is really to
fill in the gaps in knowledge and also to validate earlier research.
Based
on that, I choose four. That would be
my first choice.
DR.
GARZA: Why would you prefer that to
either one or three?
DR.
DOWNER: I think if we're looking at a
current infant formula and a new ingredient, look at what the research--the new
research that we're looking at and do the comparisons within the group.
I
think it would be helpful to have other data with which to compare and to
contrast, you know, the new information with, and that is why I say, from the
sublime to the ridiculous, perhaps, looking at the reference, one, because it's
already there.
But
I'd like to just look at the essential research, the new formula versus the
old, and see what we're looking at, just get into the meat of it.
DR.
GARZA: Dr. Anderson?
DR.
ANDERSON: I would choose either two or
three, and that's because both of those provide some reference upon which to
make comparisons among formulas.
DR.
GARZA: Would you rank them for us?
DR.
ANDERSON: They're the same to me.
DR.
GARZA: Dr. Heubi?
DR.
HEUBI: I would choose one as my first
and three as my second and probably not four.
DR.
GARZA: All right.
DR.
HEUBI: Because I think that there needs
to be some comparison to a standard, and I'm not entirely certain that I'm real
enthusiastic about the CDC standard, but I certainly believe that there should
be comparison to standards, including a breast-fed reference.
DR.
STALLINGS: One and one.
[Laughter.]
DR.
STALLINGS: You know, I think just from
what I would like to see to be able to evaluate it, but one is number one, and
I think if I had to choose another one, it would be number three.
DR.
GARZA: All right.
Dr.
Baker?
DR.
BAKER: I think the real question here
is what should the recommendation be? What's
really necessary? And so, the question
really is should we include references at all, and I believe that we should.
I
think it should be a recommendation that references be included, and I think I
would go with number one that all three references ought to be included,
because I don't see how you can decide among the others which one you want to
do.
DR.
GARZA: Dr. Briley?
DR.
BRILEY: One. I'm like Ginny. One. But if I had to go for another one, I would
go for three.
DR.
GARZA: Okay.
DR.
THUREEN: I am presuming that, with
on-line references, that it would be easy to get the three references
standardized, accessible, and relatively easy to compare data to those, and
once you set up the databases, that in the future it will be very easy to do,
and once you get to that point, I don't see why you wouldn't do one.
The
pertinent information for the formula company is primarily the two formula
comparisons, but the information that could be gained for all of us really
comes under number one, especially if it's not an excessive burden.
So,
I would say number one, and a distant second would be number three.
DR.
GARZA: Dr. Denne?
DR.
DENNE: One and two, with a preference
to one.
DR.
GARZA: Okay.
MR.
KUZMINSKI: Three.
DR.
GARZA: Three and three?
MR.
KUZMINSKI: Three and three.
DR.
GARZA: All right.
Well,
with two exceptions, everyone selected number three. With a few more exceptions, one was the next, as I read it, and
then two and four were less.
Now,
with one and three --
DR.
BAKER: I don't think you counted right.
DR.
GARZA: Well, three was, except for
Denne and for Dr. Downer, on everybody's list, I think. Number one was not as general, but it was on
most people's list but not on everyone's list, fewer than number three.
So,
let's go to number one and three, because they seem to be the most popular, and
I'll take a show of hands between one and three. You have to select between those two.
So,
those that have a preference to one, would you raise your hands?
[Show
of hands.]
DR.
GARZA: Okay. So, we have everybody but two.
And
those that would select number three.
[Show
of hands.]
DR.
GARZA: Since number one includes
three--how is that for confusion?--then I think that we're somewhat consistent
in our advice to the agency.
Most
people prefer number one. Everyone sees
the breast-fed group as a necessary reference.
There are two individuals who thought that perhaps was not necessary but
they could live with that.
All
right. Well, now, having done this, I
think we've done B, but let me make sure that you agree with me. We talked about merits and values and
ranked. All right.
Now
we are down to number 7. We could
either begin this discussion or we could--I don't know whether sandwiches are
out there.
You
could go now, take 15 minutes, bring your sandwiches is, and we could then work
through lunch and get through number 7 rather than trying to break it up.
So,
do you want to do that? Take 15
minutes. Let's get back here at
11:45. Bring your sandwiches with you,
and we will try to get through question 7, and what I'm going to do with
question 7 is to ask for a volunteer using a specific example of what would
trigger a growth study and, on the basis of that concrete example, to suggest
guidelines or criteria that led you to identifying that as an example.
Then
I'll go down the committee, asking several of you for your examples and
criteria and guidelines for coming to that example, with the hope that soon we
will hear echoes of the reasons that led you to that, and if we hear echoes,
then we should be able to get through that discussion fairly quickly, because
we would have done A, which I think is the--what we're going to be able to do.
I
don't think we're going to be able to identify all of the specific changes,
obviously, that would lead to that, but we can generalize or come up with
criteria or guidelines and give examples of how those criteria and guidelines,
if we use the strategy that I'm suggesting.
Is that acceptable to the group?
Dr.
Stallings?
DR.
STALLINGS: Thank you. I just wanted to make a couple of comments
that came up during break and to be sure that they're part of our general
discussion, as well, or knowledge.
In
talking with Roger, it appears that the industry data on breast-feeding babies,
which is extensive, might be able to be available, you know, in a form that we
could all do.
Also,
in talking with Dr. Fomon, only about a third of the data on the breast-fed
infants there have ever been published for them, so there might be an
opportunity to mine the Iowa longitudinal data set more specifically,
particularly between the birth and four-month window that we're looking at.
So,
I just wanted to mention those, that there may be better information for us in
the future, and it represents great cooperation.
DR.
GARZA: All right. Very good.
All right, then. Let's get back
at about 10 till.
[Recess.]
DR.
GARZA: I want to thank the committee
for being so compliant in having such a quick lunch.
So,
we're on to the home stretch on question number 7.
We've
got about two-and-a-half hours to get through it. So, I do think that we ought to be able to through it.
Of
course, I may have nixed it in the expression of optimism. I hope not.
I
asked the group to think about this, because I thought it would be much more
efficient if you had had a chance to reflect last night on guidelines and
criteria that one can use to determine the need for a clinical study intended
to provide assurance of normal physical growth if one took an example of what,
in your minds, would trigger such a study, and then, with that concrete
example, illustrate for the group what general principles or criteria you used
in identifying that specific example.
Let
me ask for a volunteer. Who would like
to go first?
You
notice that I didn't choose anyone, because I want to keep my friends.
There's
this great adage in food and nutrition that friends come and go, enemies you
accumulate.
No
one, huh?
Dr.
Stallings, thank you for rescuing me.
DR.
STALLINGS: Okay. So, I'll--I'm sure I don't have all the
details that Bert's really going to want, but this will at least start the
discussion.
So,
my proposal was to study term infants, and my question was, on an infant--the
term infant formula that has the soy protein--and one of the examples on the
table was that there is the potential process for stripping the isoflavones out
of that, so that you would be taking something that we have experience with,
which is soy-based feeding--that you would be making a major manufacturing
change.
So,
in theory, I said it was from the same source, assuming that the stripping and
all of that would be done by the company but that there be an assumption that
it may actually have to go to a different source.
DR.
GARZA: This wasn't soy that was grown
in a corn field.
DR.
STALLINGS: Right. And I was assuming that I would start with
the idea that the same amount of protein content--so, the grams per kilo for
baby, a normal feeding--I didn't have any intent to change that.
So,
the inclusion criteria would be term, and I think that's been described as
greater than 37 weeks, or I usually use the 38 to 42.
I
stumbled even on the exclusion criteria trying to think about what we've all
been working on, which is test the new product in the population that it will
serve, and soy basically has a number of uses.
You
know, one is cow milk protein that sometimes is used, although there are
alternative products, lactose intolerant, and then in real clinical practice,
it's often just used as the formula you try when the baby, quote, has
"feeding intolerance," so it's not really coming with a real
diagnosis.
So,
I decided not to exclude anything. It
was the decision.
And
then trying to get into a protocol--I think this kind of a chain certainly
merits a feeding study, as well as all the pre-clinical work that would have
been done.
So,
again, this was before much of the discussion today.
If
I had a wish list, then I would have had, in essence, a four-armed study. So, we may have modified that already but
that you would have a breast-feeding group as sort of a standard, you would
have your regular soy formula, you would have my new modified soy formula with
decreased isoflavones, and I was wondering about the strength of the data, and
it probably could be provided historically, but again, to look at the growth of
children on cow milk protein versus soy milk protein, just to benchmark that
difference, as well.
So,
then I was trying to think about where would I do the study, and as we all know
and have talked about, you can't exactly randomize children to
breast-feeding. That has to be a family
choice, and formula feeding is a family choice.
But
then could we have a study where we would have families' consent to be in a
study where they were randomized to regular soy protein, a new soy protein, or
regular cow milk product, whatever the comparable product would be.
Then
I had the idea that the birth weight would probably be historical, because
we're not enrolling while they're in the nursery and the stay is so short, and
then use the time-line--and I want them enrolled at least by 14 days,
preferably by eight but certainly by 14, agreed with the work we did yesterday
on weight and length and height and at the study assessments through six
months, and I was actually wishing that I could have a 12-month data point for
growth.
And
then when I looked at, here, growth being your primary outcome, trying to
follow that, there would be a number of other secondary outcomes if we were to
take this approach, and those would be really, I think, two things.
One,
part of the interest in isoflavone-reduced products is that is there any
indication of estrogen effects on babies during this time? So, there could be physical examination and
potential bio-markers, blood tests that would follow that, and those might be
done at one, three, six, and 12 months, not at every assessment, and probably
the three-month is the highest dose exposure of the formula, because it's
before most complementary feeding has started.
So,
you know, the one-month, probably the exposure is highest because of volume,
but I thought those were important.
And
then the pre-clinical and the scientific review would have given--and the
review of the actual manufacturing would have led to, are there any, for
example, vitamin and mineral blood tests that need to--are we putting anything
at risk by the time we've gone to this new manufacturing or new source, so that
there might be some other biochemical assessments that would need to be done.
So,
I came out of it with that kind of a study where growth is still the primary
outcome, but there would be two types, potentially, of secondary assessment
that I would be interested in.
One
is the estrogen, and I guess the issue there is I know that it could never be
powered to pick those up, because if they exist at all they're rare, and the
vitamin and mineral data could probably be powered reasonably well, I would
think, if there were indications from the manufacturing.
So,
that's an overview of things to --
DR.
GARZA: Okay.
As
I listened to the design of the study that you were thinking about, were the
criteria and principles that led you to that--because it was a substantially
manufacturing change, I mean the idea that we're stripping something, that one
was dealing with a potential special vulnerable population in that these kids,
if they're generally put on soy formula, it's a second formula.
It's
not generally a primary formula that's used, but either because they were
intolerant or developed lactase deficiency or whatever, but they were an
especially vulnerable population, and that there may be the involvement of
bio-active factors that could influence growth.
Are
those the sorts of criteria that led you to say, well, this is what would
trigger a growth study, and are there others that one could generalize, so that
as we look at the example that you gave, and others, one would be able to
provide some guidance to say, well, if the change involves any of these
factors, then you probably ought to think very carefully about the need for a
clinical study or, conversely, one that look at growth.
If
it doesn't meet these, don't worry about it.
DR.
STALLINGS: I think you captured what I
thought of also as my general principles.
The only thing I realized as I was getting into this is, with such a
major manufacturing change, you have to do the growth study.
If
this were to stay a marketable product, I could see there would be a time in
the foreseeable future where there might be questions that wouldn't require a
whole growth study but might be going back and doing biochemical studies, that
kind of thing, as we learn more about it, or again, you know, maybe there are
vitamins, their bio-availability, things that change and things like that.
But
yes, I think you got the major principles.
DR.
GARZA: As I compare those with Dr.
Bier's guidelines for when one would need a clinical study, the one--I mean and
he mentioned others that obviously--that I have not from that example.
The
one that didn't seem to be covered in his white paper was the involvement of a
potentially especially vulnerable population, I mean that if you're dealing
with a population such as the one that you might expect to be on soy, then you
probably ought to have a higher bar.
DR.
STALLINGS: As a clinician, also, I
think the especially vulnerable population might be the children with very
short gut and the even more specialized products.
I
think in today's environment that the soy product is so--used in so many
different indications, many of them are probably not truly especially
vulnerable.
We
use it in that group, but I wouldn't want to say that I only want to go to
children who, you know, had known, for example, protein or lactose, because it
such a commonly used--so, I was trying to use that idea, where is it really
used in modern practice, and this, I think, is generally used in many
otherwise--well, in many healthy children, not otherwise healthy children, as
well as having a special place with some specific GI or allergy diagnoses.
DR.
GARZA: Do we have another example to
help us work through identifying criteria or guidelines that would trigger a
clinical study?
Dr.
Heubi?
DR.
HEUBI: I have an example, but it's
pretty esoteric. But it's fairly
relevant.
And
that is my suggestion was a infant formula company would decide that it was
appropriate to include epidermal growth factor in their formula for inclusion
in a pre-term infant formula because there may be evidence that EGF reduces the
risk of necrotizing enterocolitis, and so, as a consequence, that addition,
since it's really not been tested in humans, ever, as far as I know, in terms
of as an enteric administration, would require a clinical trial, partly because
you don't know about safety, but also you don't know about whether it would
affect growth.
It
may actually have an enhancing quality for growth that we currently don't know.
So,
you would select a population of pre-term infants that would be probably 1,500
to 2,500 grams, the group of individuals who would be at risk, or even smaller,
for NEC, and it would require a large population of patients to study to define
whether there was really a clinically significant reduction in the rate of NEC
within that population.
It
would obviously require a comparison to a comparative formula that would be
without epidermal growth factor, and your end points would be not only
measurements of growth but also incidence of NEC, and as John presented
yesterday, it would require a large sample size to be able to answer this
question. It's a specific health claim,
yes.
DR.
GARZA: So, what one would be--you're
dealing with a factor that's not been tested in humans before in terms of in a
food in an especially vulnerable population that might involve growth. That's one, in addition to the other three
we talked about.
Another
which I thought was interesting, when you said, well, here's a factor that's in
human milk, and Dr. Bier has said, look, the fact that it is in human milk
doesn't necessarily preclude a growth factor or a growth study.
Would
you entertain the opposite one, to say, well, given the fact that any
substance, bio-active factor that we don't have experience with, other than in
human milk, should trigger one, because these are bio-active factors that act
in concert with others, and we're not quite sure they might act, in isolation
of everything else.
Epidermal
growth factor is part of human milk, but so are a number of other growth
factors. If you just provide in
isolation, what is the outcome?
DR.
HEUBI: That's a relevant question, too.
It
actually sort of begs the issue of would you try to concoct a mixture of these
to include in infant formula and do a study of that nature, but we're not
designing their study for them.
DR.
GARZA: But you're saying that anything
that--a bio-active factor, whether there is experience--recognized to be part
of human milk--is really irrelevant, I mean, that, in fact, you probably will
need a study, because we don't have an experience with that product in
isolation.
DR.
HEUBI: Yes, this is a circumstance in which
a two-tail test for growth would be absolutely essential, because you don't
know whether it might have a positive or a negative impact on growth.
DR.
GARZA: So, not being tested in humans
and its bio-active nature--that second one, I think Dr. Bier had in his paper,
as well. Okay.
Dr.
Clemens?
DR.
CLEMENS: Thank you very much.
The
hand-out you received yesterday, perhaps in the e-mail, as well, talks about
the potential change that we might see in the infant formula now, and we have
experience of what we have gone through, we might see in the future.
I
think that was a very nice example, Jim, regarding EGF.
You
see it as a flow diagram that focuses in the decision, how do you get down to
the point where you decide to make a clinical trial, and that helps us focus on
the question of item number 7.
Using
Jim's example, you can see that perhaps we don't have sufficient hands-on
information at this point in time, even though it included a breast-milk,
addition that requires a processing change under current food science and
technology.
That
would trigger, automatically, a clinical trial.
So,
what I wanted to focus on is the fact that some of the issues we'll be
discussing in the next two hours really go through this flow diagram decision
tree matrix, and then you will look at the experience in a matrix, whether
you're moving isoflavones from soy, what kind of data set are already available
in human consumption as well as other studies, what processing changes, and
maybe it's a processing change that would dictate initial clinical trials, in
addition to physiological requirements.
So,
look at nutritional adequacy as the bottom line, and if we think, in theory or
through processing or through whatever change we have to go through, the
ingredient or through the processing, that would dictate we'd expect a change
in growth or impact on nutritional adequacy, clearly we would do a clinical
study.
DR.
GARZA: Dr. Anderson?
DR.
ANDERSON: I wonder if I could follow up
and ask Virginia some questions.
I'm
way out of my content expertise here, so if I say something really stupid,
you'll forgive me.
Suppose,
prior to your study, there were two previous studies, one done by taking
isoflavones--removing isoflavones in a dietary supplement which was directed
towards the elderly and the clinical trials there were already completed and
were found to do what you expect dietary supplements in the elderly to do and
there were no impacts on adverse events.
And
suppose, in addition, there was a study in children who, because of their
medical condition, needed dietary supplements and that study had already been
done, again with the same processing to remove the isoflavones, a appropriately
conducted clinical trial showing that, in, let's say, eight-to-12-year-olds, the
product without the isoflavones produced the same effect as the product with
the isoflavones and there were no obvious adverse impacts.
How
do you feel now about the necessity for a trial in infants?
DR.
STALLINGS: Probably unchanged. The issues of exposure to the estrogen
component is, I think, very different in the very young, growing child.
The
per-kilo exposure even in the residual amounts or in the previous amounts would
be quite different, usually, from the food sources.
So,
I don't think either of those would be good models to test either the growth
question, because of the--in essence, the infant growth spurt that we've been
talking about, nor optimal for testing the question of whether very low
bio-active components are having a biological effect, and we know in newborns
that changes in some hormonal--some enzymes--that with relatively low amounts
of estrogen you can estrogenize boys and with relatively low amounts of
testosterone you can testosteronize girls.
So,
there are some things that are fairly unique in that setting, but it's a good
question. But in those two examples,
they don't meet the dose exposure, and neither of these populations would have
the growth.
The
per-kilo in health infants, the protein intake, you know, is probably two to
three grams per kilo.
By
the time you're a 12-year-old, it's probably about one gram per kilo, and
elderly, honestly, we don't have as good a handle on, but in healthy adults, we
tend to think of it being .8 grams per kilo.
So,
even the protein sufficiency question, which is inherent to changing a protein
source--probably those are not great models.
So,
I would be looking for a younger, rapidly-growing group.
DR.
GARZA: So, would we then modify one of
the criteria that Jim introduced to indicate that, in fact, it's not enough
that it hasn't been tested in humans but that it hasn't been tested in
children, so that the default ought to be, gee, do you have information that is
developmentally specific, dose specific, because of autogeny of development,
etcetera.
Okay. That was very helpful. Thank you.
DR.
SIGMAN-GRANT: But didn't we say that
what we'd require would be that the formula would be tested for the population
for which it was intended?
DR.
GARZA: In terms of triggering that, if
you had epidermal--let's assume that we had epidermal growth factor data in
humans that had been safe in the elderly or in an adult population. The fact that you didn't have it in children
would still trigger or be one of the factors that at least the FDA would use in
determining whether or not they would recommend or industry would decide to do
a clinical growth study.
Dr.
Anderson?
DR.
ANDERSON: The reason for asking the
questions is that I think that there's probably some continuum, and the
particular example here is probably not the right one, but I can sort of
imagine that there might be another instance of a major processing change in
which there was information from other sources to suggest that the
preponderance of that evidence would suggest that the change would have no
adverse impact either on growth or adverse effects, and so, I think we need to,
you know, test that boundary as we may have these discussions.
DR.
GARZA: Knowing full well that this has
been a topic of recent enormous concern nationally in terms of when you require
testing in children, I don't think we'll come to resolution on that one, and we
probably shouldn't try at this meeting.
Okay. Any other examples that will help us go
through this development of guidelines and general principles?
Dr.
Denne?
DR.
DENNE: Not so much an example but
perhaps a comment on the previous AAP guidelines about what might not trigger a
growth study, and I mean, for example, fairly wide ranges in changes in energy
concentration and very wide ranges in protein concentration by the AAP in 1988
suggested that those didn't require growth studies.
I
would think that, at present that wouldn't be acceptable. I mean a change somewhere between two and
four-and-a-half grams per hundred kilo-calories, according to the AAP, wouldn't
require a change.
It
would seem that, under our revision, that might be different, that major
changes in macro-nutrient content would require a growth study.
DR.
GARZA: This brings to mind the
suggestion that was made, I think again by Dr. Bier, that we ought to take a
look at the LSRO, DRI, and other processes to see have those ranges been
narrowed by any of that information, because those requirements have been
looked at, and I think you're right that we ought to probably go back and get
more quantitative, then we will have an opportunity to do that here, and those
may be guidelines that we can use to help determine what would be appropriate.
Dr.
Thureen?
DR.
THUREEN: Yes. I'd like to know if there's any plan to adopt the LSRO recommendations
by the FDA?
DR.
TAYLOR: In order to provide for the
final set on nutrient recommendations, we, of course, go through notice and
comment rule-making, and all available data, including that from LSRO, would be
part of the consideration. So, it will
certainly be considered.
DR.
GARZA: All right.
Any
other examples?
DR.
SIGMAN-GRANT: I had an example of
adding cholesterol to bovine iron-fortified commercial formula.
There
are some studies in baboons that suggest--there's some previous animal studies
that suggest that it, again, is a compound found in human milk.
I
looked through Dr. Bier's criteria, and it will fit under almost any one he
listed, but I think that would be an example where a growth study would be
required, particularly since it's such a controversial sort of ingredient.
DR.
GARZA: Did you find any of the general
principles or criteria that Dr. Bier discussed in his white paper inappropriate
in terms of triggering the study?
That
doesn't mean that it would necessarily be exhaustive but that, as you went
through the cholesterol example in your mind, did they all pretty --
DR.
SIGMAN-GRANT: Yeah.
DR.
GARZA: --fit in your mind that that should be looked at?
DR.
SIGMAN-GRANT: Almost every one of
them. I think addition of an entirely
new compound, it's a formula change.
Well, we don't have nutrient levels established. So, that one wouldn't apply to this.
But
compound known to affect hormones, growth factors--I think most of them, except
for the one where it hasn't previously been established.
DR.
GARZA: As I go through the list in my
mind--and I may not be remembering them all--the only two--and one could
construe, perhaps, that some of them would be inclusive in the list that he
provided in that paper--is the extra care if the formula is directed at an
especially vulnerable population and that, in fact, one ought to look very
carefully at those changes.
Premature
might fall into that group, not only the type of infants that Ginanne's example
gave us, and the addition of a new factor, but I guess that would be in there,
as well, I mean exactly.
So,
that may be the only one.
Dr.
Heubi and then Dr. Anderson?
DR.
HEUBI: My only comment about
cholesterol is it actually is present in infant formula in varying
concentrations, and the reason, actually, it would fulfill criteria probably
would be it would require a new formulation to do this, correct?
DR.
GARZA: Dr. Anderson?
DR.
ANDERSON: So, perhaps I could ask Roger
to comment, because the criterion 4 was that a study was required when an
entirely new compound was added to infant formula, and yet the decision tree
chart seems to suggest that if the additional ingredient was determined to be
generally recognized as safe for infant formula, its addition was supported by
well-accepted scientific rationale and/or experience in the manufacturer's
formulation, I assume other formulations, and raised no reasonable expectations
of a significant adverse impact, that no clinical trial was required.
DR.
GARZA: Before he answers, is there a
separate GRAS list for infant formula?
No, there is no special GRAS list for infant formula. So, it's just--you're suggesting that any
GRAS substance --
DR.
ANDERSON: No. I'm suggesting that's what the decision --
DR.
GARZA: I don't think any of us would
agree with that, but let me ask Dr. Clemens.
I mean Dr. Benton gave us examples where that could be a problem in
young infants.
DR.
CLEMENS: Even though it's GRAS, it may
not be appropriate to put in infant formula, is the bottom line, and we have to
assess the science behind putting a particular ingredient in infant formula.
If
you want to use the cholesterol issue--and thank you, Jim, for making the
comment that all milk-based formulas do, in fact, contain cholesterol at some
levels, but also the emerging science would suggest--if you want to use that as
an example--suggest there is points of addition you want to consider, what
happens to instability, and a new matrix is not associated with reliable
proteins, is not associated with microns.
So,
how is that metabolized? How does it
impact cholesterol biosynthesis or degradation? All those things need to be considered, and clearly, it's likely
that we would do not only a growth study, Madeleine, but also do a lot of
metabolic studies to justify that position before presenting it to the FDA.
DR.
SIGMAN-GRANT: It was just an example.
DR.
GARZA: I do think that it's helpful to
go back to criteria 4.
DR.
HEUBI: It was a good example, and
actually, it was a good example for maybe the wrong reason, because it actually
would require reformulation, not because it's a new addition.
DR.
GARZA: If we go to criteria 4, though,
the example that Dr. Anderson just gave us about GRAS substances, criteria 4,
as suggested in Dr. Bier's paper, doesn't make a distinction between GRAS and
non-GRAS substances, just as if it's a new compound in infant formula.
DR.
THUREEN: Dr. Garza?
DR.
GARZA: Yes?
DR.
THUREEN: Maybe I could comment. And this is an example from the decision
tree paper. They said here are examples
of substances that may not necessarily require a clinical trial, and it said
"addition of minor constituents added for potential nutrient contribution
but for which there is no reasonable basis to predict that they would materially
impact nutritional adequacy," and the example was L-carnitine.
I
thought that was a curious example and that that's sort of a new ingredient
that I think has been put in great question, and the implication here was that
you didn't necessarily need to study it, because it's well enough understood.
DR.
GARZA: I think the decision tree is
very useful for your background, but it's not something that is on the table as
something we're going to adopt.
DR.
THUREEN: Right.
DR.
GARZA: If we start doing that, then we
have to go--also, there's been another decision tree that was suggested to us
by Dr.--or Ms. Heiser to treat it as a drug, and I don't want to go down that
path.
DR.
THUREEN: I didn't mean to talk about
the decision tree specifically. It's
just that this is a new product that I think would, by definition --
DR.
GARZA: It's an example like the
cholesterol one.
DR.
THUREEN: Another example.
DR.
BAKER: I'm sort of--I'm going to give
another example, and I'm a little bit afraid of what's going to happen with
this, but looking at the decision tree again, to me, it does seem like the
decision tree does reflect some thinking about what are in the regulations.
So,
I think the decision tree is worth looking at.
I
do note, however, if you get down into the bottom of these, it always comes to
a study is unlikely or likely.
You
still have to make that decision, and actually, we're working below the
decision tree. We're trying to decide
how to decide this last thing in the decision tree.
DR.
GARZA: Well, to the degree, Dr. Baker,
that you can take--extract either general principles or criteria that you think
the group ought to be considering from either that tree or anything else we've
heard, that's fine, but it's not the tree we're looking at.
DR.
BAKER: We are actually looking at the
bottom box of this decision tree, so that what goes before that is not really
relevant. Well, it's relevant, but it's
not what we're considering at this time, and the reason I'm bringing the
example up that I am going to is that, if you follow the decision tree and what
the industry has given us, you probably wouldn't have to do a growth study in
this case, but I think you clearly would if you follow my logic here.
The
example--I don't want to embarrass the FDA, but the example is boiling water to
powdered formula for pre-term infants, and this was suggested because--it was
to eliminate contamination in powdered formula, and the industry has said, if
they have a recommendation from an expert body, that they would accept--would
make that change without a study.
But
it's very clear that boiling water to powdered formula changes all sorts of
things in a formula, and it would definitely--if you were going to actually go
through with that--fortunately, we have backed off that a little bit and we're
not going to go through with it, but if you were, it would definitely require a
growth study.
DR.
GARZA: So, that would be based on the
general principle that if you're going to change the composition--so, if you're
going to be changing the nutritional composition of the formula--I think
that's, again, one of the criteria in Dr. Bier's paper.
Dr.
Downer?
DR.
DOWNER: In doing my assignment last
night, I looked at iron, and we know that most of the formula in the United
States do use ferrous sulfate, and I wanted to see, if we were to use a
different form of iron, it might have been interesting to look at, in general
principle, what some other criteria would be to address this.
Again,
this is not factual, just hypothetical.
That's what we're going from.
And so, in general, I think that would trigger, I think--and essentially
what would trigger the growth study would be if there were any--looking at
bio-availability.
That
would be something that I'd like to look at.
Also,
the impact of this new iron source on the other nutrients that would be
available. So, how would it impact?
Also
to look and see if this new product, whatever this new iron source is, how
would it perform at least with the old product and also against breast milk
formula?
I'd
also look for metabolic, physiological, and endocrinologic changes in the new
formula, and also look to see how this new iron formula would impact on growth,
particularly the growth parameters that we set forth, and of course, taste would
be something I would look at, acceptability for the infant.
So,
those are some of the things that I noted here.
DR.
GARZA: So, that would still fall under
the new formulation. If you're going to
reformulate it, then for all those reasons, you would want to --
DR.
DOWNER: Yes.
DR.
GARZA: Okay.
DR.
GARZA: Dr. Kuzminski.
MR.
KUZMINSKI: Thank you.
We
did not collaborate, but I chose exactly the same example.
But
I think--and I was being a little bit more specific, but some of the industry
may consider a frivolous recommendation of changing not just the source but
source and type, ferrous sulfate to an encapsulated reduced iron, where the new
technology may provide stability to the reduced iron, and so, we're assessing
the effect of the efficacy of the encapsulation and then also the impact upon
the other nutritional components of the formulation.
If
this is new technology and is driven by supplier problems with the traditional
source of iron, ferrous sulfate, then a criteria also may be the existence or
non-existence of internal experience with the new component, whereby this
particular example may, in itself, not drive the need for a growth study but
may have an effect on other components within the formulation, chemically,
organoleptically, for acceptance that may drive the need for a confirmatory
study, if you will, a growth study.
DR.
GARZA: So, again, it would be a new
formulation, in essence.
MR.
KUZMINSKI: New compound.
DR.
GARZA: I am not hearing marked
deviations from at least the background material that we got both from the
agency or from Dr. Bier or necessarily the general principles that are outlined
in anything we've heard in any of the presentations.
Is
that because it's too complex an issue that we can deal with or because
everybody's exhausted, that you gave it enough thought?
How
about some of you that have not given us your examples?
DR.
THUREEN: I have an example of a
pre-term study, which we haven't addressed, and my example was a new fat gland
with possible enhanced growth, fatty acid profiles more like infants fed breast
milk, possible lower cholesterol levels in infancy and possible positive
effects in neuro-development outcome.
This
product has been studied in term infants and shown essentially no effect in
growth, but there was a slight tendency towards long-term neuro-developmental
positive benefit, and those studies had only gone out to 18 months, and now
this was to be studied in pre-term infants, though there had been recent
reports of increased diarrhea in term infants.
So,
the objectives were to study this in this new pre-term infant population, and
what would make it different is that it would be a new population, essentially
that had not been studied before, a vulnerable population.
We'd
want to study effects in neuro-development outcome and look at effects on
growth, and this would not only definitely require a growth study but may
require a more detailed study done, both fat digestion and level of fat
digestion, so we may need nutrient balance studies, and maybe micro-nutrient
studies in case there was increased fat mal-absorption.
You'd
have to look at absorption of other studies.
So,
this is in the category of effects on absorption of other nutrients.
DR.
GARZA: But also, I mean there would be
a formula that is now going to be intended for a brand new population that's
never been tested. So, in essence, it's
a brand new formulation.
DR.
THUREEN: And new formulation.
DR.
GARZA: And that would go ahead and
trigger, than, a study, because it would be intended now for a population whom
it had never been evaluated, and I think that's not a guideline or a criterion
that is in Dr. Bier's paper. I think it
is part of--maybe not--of the other background material we got from FDA.
Dr.
Clemens?
DR.
CLEMENS: Actually, I appreciate the
comment on iron. I did research on iron
over 20 years ago, so that's pretty close to my heart. Actually, ferrous sulfate is a good example,
and we've used it in infant formula for a lot of years, and if there's a
change, emerging technology, yes, all the studies that have been
suggested--metabolic studies, balances studies--those kinds of things are
already addressed in the academy guidelines.
In
addition to the fatty acid issue that you addressed in pre-term, those, too,
are addressed in the academy guidelines.
You
change the fat source, change the growth profiles that are significant based on
the scientific evidence, we actually do the digestibility issues, we address
the balance issues, we look at stools, we look at a lot of different things, as
you can imagine.
So,
both kinds of guidelines were in place, and based on scientific background, the
knowledge and experience again, we actually won't trigger clinical trials,
because it's your point, it makes good sense.
DR.
GARZA: Dr. Sigman-Grant?
DR.
SIGMAN-GRANT: What about an ingredient
that's, say, genetically engineered or produced through a different
technique? Would that be something that
might require a different criterion, if it's the same ingredient but production
is different?
DR.
CLEMENS: That's a fair question. I can give you two examples.
We
look at canola oil, based in Canada.
It's a low-erucic acid, a seed oil, and we've agreed in this country not
to use it.
Matter
of fact, a number of organizations across the world have agreed not to use it
because of the presence of erucic acid, and we certainly concur with that in
the pediatric population, even though Codex, I think, agreed that it could be
used.
WHO,
however, has not agreed that it should be used in infant formula.
In
terms of protein, let's say, biotechnology, all the soy protein used in this
country in infant formula is, in fact, Monsanto-derived, and it is through
years of usage and growth studies, it's been deemed to be nutritionally
adequate.
Now,
if there's a new ingredient that's on the table, in fact, we would study it
just as rigorously as anything else.
DR.
GARZA: Would that trigger a study
because it was a new source? What that
considered a new source of soy and, therefore, a new formulation and,
therefore, was re-studied when they made the transition from traditionally bred
to genetically modified soy?
DR.
TAYLOR: The answer to your question is
a very difficult one, because you know, we're standing on the precipice of what
does that mean, and remember, it's GRAS for intended use. So, there's GRAS for whatever the end point
is, and I'm deliberately not going to answer your question, because I don't
think we have a history of knowing how to answer your question.
DR.
GARZA: All right. The only reason I was curious is because we
have one guideline that says, if you have a new source--so, if the new source
is a new source --
DR.
TAYLOR: What is it? You know, we're back to that problem. Is it a new source? If it is a new source, it's down on
path. If it's not a new source, it's
down the other.
So,
new source, yes, but what's a new source.
DR.
GARZA: It's a good point, because in
fact, one looks at the criteria that says new source, and it's a definition of
not what is is but what is new and whether, in fact, one would find, if the
source has been modified in any way, whether that qualifies as new.
Dr.
Briley.
DR.
BRILEY: I just wanted to ask who
identifies whether it's a new source or not?
Does the industry? Who does the
identification?
DR.
GARZA: Who has the regulatory
responsibility to identify if somebody switches from one source to another?
DR.
TAYLOR: This is a notification process,
so the manufacturer comes in with a package.
We have the right to object or not object.
So,
they could assert it's a new source or assert it isn't a new source, and then
it comes under our review.
So,
it starts with them, and then we, of course, review the package.
DR.
GARZA: For example, let's assume that
BT corn, tomorrow, would become a significant source of some unsaturated fatty
acids.
It
would be the responsibility of the manufacturer to notify FDA that, in fact,
the source of the fatty acids had now changed from a conventional corn to BT
corn, or would you be required to identify the change by your own monitoring
techniques, so it would be the manufacturer that--so, it's their judgement as
to whether it's new or not.
DR.
TAYLOR: We're talking about 412, which
is the finished product. I want to
distinguish between the 409 review, which is the actual individual ingredient
and its coming in for GRAS, which is a preliminary process, separate from the
412, which is once everything--the individual ingredients are deemed safe, once
you put it together, it works.
Now,
that whole notion of working is where new source comes in. So, it's a very complicated world, but no,
we don't have a monitoring to see what the industry is using for these
formulations, if that's your question.
DR.
GARZA: Does that help clarify it? Thank you.
Because that's very helpful.
Dr.
Anderson?
DR.
ANDERSON: I'd ask Dr. Thureen to
consider the reverse of the trial that she suggested.
Suppose
that the previous study was done in well preemies and they were studied through
to six months after expected delivery and that it all turned out exactly the
way one wanted it to, and now the interest is in marketing this to term
infants.
Do
we need a clinical study?
DR.
THUREEN: I think it would require a
clinical study, because I think you have to assess growth.
It's
a new formulation in a different population, physiologically different
population. I think it would need
study.
DR.
GARZA: Would anyone disagree with that?
So
that, as a general principle, anytime you move to a population other than the
originally intended one, that the default ought to be a new study.
Obviously,
people can submit information as to why that may not be appropriate, but that
ought to be a trigger in considering the need for one, as a general principle.
Can
you think of circumstances where that general principle would not--wouldn't
even come into play?
Dr.
Stallings?
DR.
STALLINGS: It's hard to think of one
that we could do theoretically, and I think we've got to remember that, if we
use the population that you intend to treat, the pre-term infant formula will
be fed to babies who are still in intensive-care units and are generally very
sick.
Now,
they're not so sick that they're not getting enteral formula, which is a point
in the spectrum, but they're also capable of getting sepsis or any number of
other things during that grower and gainer phase.
So,
I think it is a very different time, and anything designed for that and shown
safe there actually might have--might theoretically have a different effect in
truly term babies without all of the stresses of being premature and in
intensive care units.
So,
I would have--I'm sure if we sat and thought, we could think of something, but
as I go through it, I mean, you know, energy, electrolytes, all of
those--osmolality--all of those things are very different from the very young,
critically ill--the small, critically ill baby to the term baby.
So,
I would be hard pressed to do it.
DR.
GARZA: Okay.
Dr.
Anderson?
DR.
ANDERSON: I can't imagine why one would
do this, but suppose that the study of a new infant formulation was tested
exclusively in full-term, low-birth-weight children, because there was an
available source.
Would
that be sufficient for marketing to normal term infants?
I'm
trying to stretch the boundaries here.
DR.
MOYER-MILEUR: My response would be no,
because you're again looking at a special population that, in utero, has
suffered some type of nutrient deprivation, even though they're born at term,
and so, then to apply that may work in that population may essentially overfeed
or over-nourish a healthy population.
So,
I still think you're working with a different population.
DR.
GARZA: We have a number of presenters,
and I'd like to ask whether, in fact--those of you that represented
yesterday--are there other criteria or guidelines that, in fact, you haven't
heard raised that you think the group ought to consider in going through this
discussion?
[No
response.]
DR.
GARZA: Okay. All right. Well, I don't
know whether we're going to--maybe we're done.
I
don't know whether we're going to get anymore from the group, other than if we
look at the guidelines, the criteria that are here, the discussion that we've
had, I am not sensing that, in fact, we see that this is a deficient list in
other than the few ways that we've talked about, and that is, if you have a
potentially vulnerable population, that probably that ought to be thought
through more carefully.
Everything
else seems to pretty much under one of the existing guidelines or criteria.
The
only other issue that's come up is that, under criteria four, that, in fact,
that is a new--in Dr. Bier's paper--that that is under any entirely new
compound.
Whether
it's GRAS or not is seen as irrelevant, that if it's new, then there ought to
be scientific data or something to back it up, but it ought to, by default, be
considering as triggering a growth study, assuming that you had appropriate
animal studies and everything else that showed that it was going to be safe in
this population, obviously.
All
right. Well, then you've accomplished
what I thought was impossible, which is very nice, and that is to get through
this meeting early. I didn't think we
were going to be doing that. I thought
we'd be here till 3:00 o'clock and that this would elicit a lot more debate.
I
thought we were going to be there with the genetically modified discussion that
Dr. Sigman-Grant opened up, and I think that that would still fall under the
criteria that we now have.
DR.
HEUBI: So would pre-biotics, too. So, it's actually--it all falls under that
category.
DR.
GARZA: That's right.
DR.
STALLINGS: Now that you're making us
talk about it some more, just in the sense of clarification, as I understand
it, though, it still would be based on industry deciding that changing from
traditional to genetically modified sources constituted a new source versus
this soybean or this soybean, that sort of thing.
So,
maybe what--I can go back to Roger and say, does industry consider those kinds
of--I mean particularly--I mean what we might have said 10 years ago when we
first started thinking about this versus where the public interest and elements
of trust and all those other things are.
So,
does industry--would that merit calling the FDA and saying we've just changed
growers or our growers changed seeds for the soybeans?
DR.
CLEMENS: We may not go back to the
growers and say that our growers have changed seeds, but we do work--the
industry does work very closely with the various suppliers of ingredients, and
if they change their process, they change their technology, the industry knows
about it, and they take it very seriously, if, in fact, they believe it will
change the physical characteristics, as it was mentioned this morning, of that
particular product, it will impact on nutrient bio-availability, if it impact
on processing, ultimately will impact on growth, and if, under all those
criteria, if we feel that it could impact negatively in any of those aspects,
we will, in fact, do additional study, if warranted.
So,
they are very, very sensitive to the change of ingredients, anything that the
suppliers will do. Be assured with
that.
DR.
STALLINGS: Just to follow up--but the
truth is, many of us think that changing the soybean source wouldn't do any of
those things, but yet, we've not had a lot of experience in that.
So,
the issue of--it's assumed to--you know, how are we going to make those
decisions as some of the new agricultural products come down the line?
I
mean it really isn't like traditional genetic engineering--breeding practices,
the old thing, we're going to make a better soybean--hybridization, thank you.
So,
it still is an issue of a value judgement or somebody going, you know, even
though this is the commonly used source now, does it have any human impact, you
know, and maybe the infants will be the canary, you know, in the cave, because
they are the--probably among our most vulnerable and certainly the most rapidly
growing.
So,
you know, you guys have a lot of responsibility in this setting, because if you
don't bring it up, the FDA doesn't have the authority to come and ask you those
questions, the way the relationship stands.
DR.
GARZA: Well, let's not get into this
discussion, because we won't solve it, and it's part of 409, as we were told,
rather than 412, and for those of you that were listening yesterday, that means
that we're dealing with 412 and not 409.
I
mean it is a serious issue, but it does come under another section, and one has
to look at issues that go way beyond what we have time for in terms of
isoflavone content.
I
mean there are lots of things that you would want to think about in changing
from one formulation to another and potentially bio-active products being
involved.
So,
with that, let me thank everyone, unless there are other issues that are
outstanding that relate to section 412 that we need to cover before we break
up.
Dr.
Baker?
DR.
BAKER: I just have one last--does this
mean that we're leaving the AAP 1988 guidelines intact?
DR.
GARZA: We have not been asked to
comment on the criteria. We've gone
through the seven questions.
I
think we've provided the answers that we were asked to give, whether it's three
grams or two grams or one gram.
We
can certainly be asked to come back and deal with that issue, but I think if we
do that, then we need to look at functional outcomes much more carefully.
We've
had some statistical presentations as to why two may be better than three and
why even less than two--I think it was Dr. Grummer-Strawn's paper that said .2
standard deviations would get us to an even smaller--then there's the whole
issue of non-linear versus linear, does it mean anything to say .3 over the
first four months or three grams a day when you know you've got a very
non-linear--I mean, so--okay.
Dr.
Taylor.
DR.
TAYLOR: I'm going to do a formal thank
you, if you're ready for a formal thank you.
DR.
GARZA: Thank you.
DR.
TAYLOR: On behalf of the agency, we do
want to thank this task force very much for their involvement and input and, of
course, all of the great speakers that we had today.
So,
we're very pleased. You've provided a
lot of food for thought, and we look forward to future discussions.
So,
thank you.
DR.
GARZA: Dr. Anderson.
DR.
ANDERSON: At least on behalf of myself,
I'd like to say how very helpful the white papers were.
In
fact, they were, I thought, extraordinarily well-done, and I think that anyone
observing the discussions--our discussions this afternoon and today realize how
extremely important they were to forming our own views about these issues.
DR.
GARZA: That's very key, and I think one
of the reasons we were able to get through this as efficiently as we did was
because of both those white papers and the presentations. So, you know, thank you.
DR.
BRILEY: I want to say, on behalf of
myself and probably the rest of the group, how great you are as a leader, and
we appreciate so much what you've done.
DR.
GARZA: Thank you very much. That's very kind.
All
right. Well, have a great trip home,
and I suspect we'll be meeting again.
[Whereupon,
at 12:57 p.m., the interview was concluded.]