Randomized Double-Blind Controlled Trial of Bovine Lactoferrin for Prevention of Diarrhea in Children

doi:10.1016/j.jpeds.2012.07.043

The Journal of Pediatrics

Volume 162, Issue 2, February 2013, Pages 349-356

https://doi.org/10.1016/j.jpeds.2012.07.043 Get rights and content

Objective

To determine the effect of bovine lactoferrin (bLF) on prevention of diarrhea in children.

Study design

We conducted a community-based randomized double-blind placebo controlled trial comparing supplementation with bLF vs placebo. Previously weaned children were enrolled at 12-18 months and followed for 6 months with daily home visits for data collection and supplement administration. Anthropometric measures were done monthly.

Results

Five hundred fifty-five children were randomized: 277 to bLF and 278 to placebo; 65 dropped out; 147 894 doses were administered (92% compliance). Overall there were 91 446 child-days of observation and 1235 diarrhea episodes lasting 6219 days. The main pathogens isolated during diarrheal episodes were norovirus (35.0%), enteropathogenic E coli (11.4%), Campylobacter (10.6%), enteroaggregative E coli (8.4%), enterotoxigenic E coli (6.9%), and Shigella (6.6%). The diarrhea incidence was not different between groups: 5.4 vs 5.2 episodes/child/year for bLF and placebo, respectively (P = .375). However, the diarrhea longitudinal prevalence was lower in the bLF group vs placebo (6.6% vs 7.0%, P = .017), as well as the median duration of episodes (4.8 vs 5.3 days, P = .046), proportion of episodes with moderate or severe dehydration (1.0% vs 2.6%, P = .045), and liquid stools load (95.0 vs 98.6) liquid stools/child/year, P < .001). There were no adverse events related to the intervention.

Conclusions

Although there was no decrease in diarrhea incidence, longitudinal prevalence and severity were decreased with LF.

Section snippets

Methods

A community-based randomized double blind placebo-controlled trial was conducted in children from Lima, Peru, comparing twice daily supplementation with bLF vs placebo administered for 6 months with monitoring of diarrhea and growth.

Eligible children were previously weaned at 12-18 months old. Exclusion criteria were a history of severe, persistent, or chronic diarrhea, severe malnutrition, serious infections requiring hospitalization in the month prior, serious chronic illness, or a personal

Results

The study was conducted from January 2008 through May 2011. The census of 52 144 households found 3674 children in the targeted age range. The food-intake survey found 2495 children still breastfeeding (67.9%) leaving 1179 eligible children (Figure). A lower than expected enrollment rate together with a much lower than expected drop out rate and much higher than expected illness rate, resulted in 555 rather than 602 children enrolled; 277 were randomized to bLF and 278 to placebo. Eighty-nine

Discussion

This study failed to achieve its primary objective of demonstrating decreased incidence of diarrheal disease with bLF as well as the secondary objective of demonstrating improved growth. However, measures of severity were positively affected although the benefit was small. The data suggest that chronic use of bLF such as is currently done in some infant formulas is unlikely to have a major impact on diarrhea in children. LF without other breast milk factors may have limited value. LF might have

References (31)

R.E. Black et al.
Global, regional, and national causes of child mortality in 2008: a systematic analysis
Lancet
(2010)
G. Jones et al.
How many child deaths can we prevent this year?
Lancet
(2003)
A.L. Morrow et al.
Human milk protection against infectious diarrhea: implications for prevention and clinical care
Semin Pediatr Infect Dis
(2004)
O. Hernell et al.
Iron status of infants fed low-iron formula: no effect of added bovine lactoferrin or nucleotides
Am J Clin Nutr
(2002)
T.J. Ochoa et al.
Effect of lactoferrin on enteric pathogens
Biochimie
(2009)
R.L. Guerrant et al.
Malnutrition as an enteric infectious disease with long-term effects on child development
Nutr Rev
(2008)
C.G. Victora et al.
Infant feeding and deaths due to diarrhea. A case-control study
Am J Epidemiol
(1989)
B. Lönnerdal
Bioactive proteins in human milk: mechanisms of action
J Pediatr
(2010)
J.H. Brock
The physiology of lactoferrin
Biochem Cell Biol
(2002)
B. Lönnerdal
Nutritional roles of lactoferrin
Curr Opin Clin Nutr Metab Care
(2009)

F. Berlutti et al.

Antiviral properties of lactoferrin–a natural immunity molecule

Molecules

(2011)

B.J. Appelmelk et al.

Lactoferrin is a lipid A-binding protein

Infect Immun

(1994)

K. Brandenburg et al.

Biophysical characterization of lipopolysaccharide and lipid A inactivation by lactoferrin

Biol Chem

(2001)

H.F. Gomez et al.

Human lactoferrin impairs virulence of Shigella flexneri

J Infect Dis

(2003)

T.J. Ochoa et al.

Lactoferrin impairs type III secretory system function in enteropathogenic Escherichia coli

Infect Immun

(2003)

Cited by (83)

Quantification of lactoferrin in human milk using monolithic cation exchange HPLC
2023, Journal of Chromatography B: Analytical Technologies in the Biomedical and Life Sciences
Human lactoferrin (hLF) is one of the most important whey proteins in human milk, known for its ability to modulate innate host immunity and multifunctional activities for neonatal growth. The objective of this study was to validate an efficient method for the detection and quantification of hLF using a unique technology of cation-exchange high-performance liquid chromatography (HPLC) on CIM® monolithic columns. Human milk samples were collected using manual expression or a breast pump, at different weeks of lactation. After sample preparation, hLF was detected and measured by HPLC method and further confirmed by SDS-PAGE. Selected fractions were analysed also by LC-MS/MS. Presumably, due to the high density of positive charge on the surface of the N-terminal domain, hLF binds strongly to the column and elutes last, enabling the high specificity of this method. The LC-MS/MS analysis indicated that hLF eluted in two clearly separated peaks, presumably representing two different molecular species of hLF. hLF concentration in the human milk samples ranged from 2.03 mg/mL to 5.79 mg/mL and was not significantly affected by the sample collection method whereas it was negatively correlated with the stage of lactation. These results suggest that cation exchange chromatography is an accurate, efficient, and robust method for the detection and quantification of hLF.
Dose effect of bovine lactoferrin fortification on diarrhea and respiratory tract infections in weaned infants with anemia: A randomized, controlled trial
2021, Nutrition
The aim of this study was to explore the dose effect of bovine lactoferrin (bLF) fortification on the morbidity of diarrhea and respiratory tract infections in weaned infants with anemia.
A total of 108 infants with anemia, who were exclusively breast fed at 4 to 6 mo and weaned and formula fed at 6 to 9 mo, were recruited. The eligible infants were randomly assigned to fortified group 0 (FG0), fortified group 1 (FG1), or fortified group 2 (FG2) and were given formula fortified with 0 mg/100 g, 38 mg/100 g, and 76 mg/100 g of bLF, respectively, for 3 mo. The morbidity of diarrhea and respiratory tract infections (RTIs), the duration of respiratory and diarrhea-related illnesses, and the levels of fecal human beta-defensin 2 (HBD-2), cathelicidin LL-37 (LL-37), secretory IgA (sIgA), butyrate, and calprotectin were assessed.
After the exclusion of 12 dropouts, the primary outcome measures, including episodes and duration of diarrhea and RTIs during the intervention, were obtained from 96 infants (35, 33, and 28 in FG0, FG1, and FG2, respectively). Compared with infants in FG0, there was a lower morbidity of rhinorrhea, wheezing, and skin rash among infants in FG1 (P < 0.05) and a lower morbidity of respiratory-related illness and wheezing among infants in FG2 (P < 0.05). Furthermore, a lower morbidity of diarrhea-related illness, diarrhea, vomiting, and nausea was observed among infants in FG2 than those in the other two groups (P < 0.05). In addition, the FG1 infants had a lower morbidity of vomiting and nausea than the FG0 infants (P < 0.05). The HBD-2, LL-37, sIgA, and calprotectin levels were significantly higher whereas the butyrate level was significantly lower in the FG2 infants than in infants in the other two groups after 3 mo of intervention (P < 0.05).
The bLF-fortified formula was effective in reducing the morbidity of diarrhea and RTIs in infants with anemia, with the 76 mg/100 g bLF-fortified formula exhibiting a stronger effect. The bLF fortification could be a new strategy for the prevention of diarrhea and RTIs in infants with anemia.
Effects of lactoferrin on infectious diseases in Japanese summer: A randomized, double-blinded, placebo-controlled trial
2021, Journal of Microbiology, Immunology and Infection
To investigate the effects of lactoferrin (LF) on infectious diseases in Japanese summer.
An intake of placebo, 200 mg, or 600 mg of LF were administered to healthy adults in Kyushu University of Health and Welfare for 12 weeks in a randomized, double-blinded, placebo-controlled parallel-group comparative trial. The primary endpoints were the prevalence and duration of infectious diseases and changes in immune parameters.
Three hundred and ten subjects were randomized (placebo, n = 104; 200 mg, n = 103; 600 mg, n = 103). Twenty subjects were lost to the follow-up, leaving 290 for a full analysis set (n = 99; n = 95; n = 96). The duration (day) of total infectious diseases was shorter in the 200 mg group (2.0, p = 0.045) and 600 mg group (2.0, p = 0.010) than in the placebo group (3.0). The duration of summer colds was shorter in the 600 mg group (2.0, p = 0.036) than in the placebo group (3.0). No significant differences were observed in the prevalence of infectious diseases or changes in immune parameters. In exploratory investigations, changes in the neutrophil phagocytic capacity, cortisol concentrations, and T score of “Vigor/Activity” in the Profile of Mood States 2 were greater in the 600 mg group than in the placebo group, when analysis was done on the lower half groups at the baseline. Adverse events were similar in each group and none had a causal relationship with the intake of the test foods.
In summer, the intake of LF attenuates infectious diseases, including summer colds.
Associations of Human Milk Oligosaccharides and Bioactive Proteins with Infant Morbidity and Inflammation in Malawian Mother-Infant Dyads
2021, Current Developments in Nutrition
Human milk oligosaccharides (HMOs) and bioactive proteins likely benefit infant health, but information on these relations is sparse.
We aimed to examine associations of milk content of HMOs and bioactive proteins with incidence and longitudinal prevalence of infant morbidity (any illness, fever, diarrhea, acute respiratory infection, and loss of appetite) and markers of inflammation [C-reactive protein (CRP) and α-1-acid glycoprotein (AGP)]. These are secondary analyses of a randomized controlled trial.
Breast milk samples at 6 mo postpartum (n = 659) were analyzed to quantify absolute abundance of HMOs, relative abundance of fucosylated HMOs, sialylated HMOs, and 51 individual HMOs, and concentrations of 6 bioactive proteins (lactalbumin, lactoferrin, lysozyme, antitrypsin, IgA, and osteopontin). We examined associations of these constituents with infant morbidity from 6 to 7 and 6 to 12 mo, and CRP and AGP at 6 and 18 mo, considering maternal secretor status [presence or absence of the functional enzyme encoded by the fucosyltransferase 2 gene (FUT2) ] and adjusting for covariates and multiple hypothesis testing.
In secretors there were positive associations between total HMOs and longitudinal prevalence of fever (P = 0.032), between fucosylated HMOs and incidence of diarrhea (P = 0.026), and between lactoferrin and elevated CRP at 18 mo (P = 0.011). In nonsecretors, there were inverse associations between lactoferrin and incidence of fever (P = 0.007), between osteopontin and longitudinal prevalence of lost appetite (P = 0.038), and between fucosylated HMOs and incidence of diarrhea (P = 0.025), lost appetite (P = 0.019), and concentrations of AGP and CRP at 6 mo (P = 0.001 and 0.010); and positive associations between total HMOs and incidence of lost appetite (P = 0.024) and elevated CRP at 18 mo (P = 0.026), between lactalbumin and incidence of diarrhea (P = 0.006), and between lactoferrin and elevated CRP at 18 mo (P = 0.015).
Certain HMOs and bioactive proteins were associated with infant morbidity and inflammation, particularly in nonsecretors. Further research is needed to elucidate the causality of these relations.
This trial was registered at http://clinicaltrials.gov as NCT01239693.
Oral lactoferrin administration does not impact the diversity or composition of the infant gut microbiota in a Peruvian cohort
2023, Microbiology Spectrum
Network analysis identifies a gene biomarker panel for sepsis-induced acute respiratory distress syndrome
2023, BMC Medical Genomics

View all citing articles on Scopus

: Funded by National Institute of Child Health and Human Development, USA (Public Health Service award R01-HD051716). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Child Health and Human Development or the National Institutes of Health. The authors declare no conflicts of interest.

: Registered at ClinicalTrials.gov: NCT00560222

View full text

Original ArticleRandomized Double-Blind Controlled Trial of Bovine Lactoferrin for Prevention of Diarrhea in Children

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

Lancet

Lancet

Semin Pediatr Infect Dis

Am J Clin Nutr

Biochimie

Malnutrition as an enteric infectious disease with long-term effects on child development

Nutr Rev

Infant feeding and deaths due to diarrhea. A case-control study

Am J Epidemiol

Bioactive proteins in human milk: mechanisms of action

J Pediatr

The physiology of lactoferrin

Biochem Cell Biol

Nutritional roles of lactoferrin

Curr Opin Clin Nutr Metab Care

Antiviral properties of lactoferrin–a natural immunity molecule

Molecules

Lactoferrin is a lipid A-binding protein

Infect Immun

Biophysical characterization of lipopolysaccharide and lipid A inactivation by lactoferrin

Biol Chem

Human lactoferrin impairs virulence of Shigella flexneri

J Infect Dis

Lactoferrin impairs type III secretory system function in enteropathogenic Escherichia coli

Infect Immun

Original Article
Randomized Double-Blind Controlled Trial of Bovine Lactoferrin for Prevention of Diarrhea in Children