Sustainable Intervention of Supplementation to Improve Kid's Growth Study

Study Overview
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Brief Summary
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Our earlier research has highlighted a high prevalence of anaemia, micronutrient deficiencies, and impaired infant growth among lactating women and infants in Sumedang district, West Java, Indonesia that were associated with large deficits in their micronutrient intakes. In response to these disturbing findings we have developed the micronutrient- enriched crackers (MEC) based on powdered eggshells and chicken liver, a readily available and affordable, local animal-source food. We will supply these MEC or a placebo, manufactured locally, weekly to a group of women in Sumedang district from 14 weeks gestation to 5 months post-partum in an effort to enrich the micronutrient content of the daily diets of the treatment group so they no longer have any dietary shortfalls in micronutrients. Our overall aim is to determine if MEC consumed daily by mothers for 6 months during pregnancy improves the birth length of their infants, and if daily consumption of MEC is continued daily to 5 months post-partum enhances infant linear growth compared to the placebo.

Detailed Description
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A double-blind two-phase cluster randomized controlled trial (RCT) will be conducted in West Java, Indonesia to determine whether daily consumption of MEC from 14 weeks' gestation to delivery improves birth length compared to placebo (Phase 1) and whether daily consumption of MEC from 14 weeks gestation to 5 months post-partum improves attained linear growth of infants at age 5 months and linear growth velocity of infants from birth to age 5 months compared to placebo (Phase 2). A total of 308 pregnant women will be recruited through midwives/public health centre from 28 clusters (villages) in Sumedang district. Clusters will be randomly assigned to receive placebo or micronutrient- enriched crackers (MEC) daily, distributed by cadres from 14 weeks gestation to 5 months post-partum. Women who fulfil trial criteria (20 pregnant women from each cluster) will be randomized and the first 11 eligible pregnant women will be invited to participate in the RCT. We will have 2-3 rolling recruitments to obtain the number of participants required. Placebo and MEC (based on powdered eggshells and chicken liver) will be manufactured locally according to Standard Operational Procedures (SOPs), so they are identical in size, color, and packaging, with a code known only by the local production manager. The code will not be shared until the primary outcome has been analysed statistically or if requested by the Ethics Committee and/or Data Safety Monitoring Board (DSMB).

Official Title
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Double-Blind Cluster Randomized Controlled Trial of Chicken Liver and Eggshell Crackers in Mothers During Pregnancy and Lactation in a Disadvantaged Setting in Indonesia

Conditions
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Birth Length, Linear Growth, Micronutrients, Dietary Intakes

Intervention / Treatment
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* Dietary Supplement: Micronutrient Enriched Crackers (MECs)
* Dietary Supplement: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Pregnant women Gestational age 12-13 weeks at the time of the screening process and be willing to take part in an intervention study at 14 weeks gestation Permanent residents who do not plan to move in the next 2 years Exclusion Criteria: Mothers who have chronic diseases such as hypertension (blood pressure > 140/90 mmHg) or under treatment for hypertension, diabetes (non-fasting blood sugar >200 mg/dL)/ under treatment for diabetes, hypercholesterolemia (blood total cholesterol >240 mg/dL), hyperuricemia (blood uric acid > 6 mg/dL), have had a history of tuberculosis or under treatment for tuberculosis; or under treatment for other chronic diseases that required a long treatment, such as cancer, heart disease, epilepsy, etc. Have a history of preeclampsia/eclampsia and gestational diabetes in their previous pregnancy Have a risk of chronic energy deficiency (mid-upper arm circumference < 23.5 cm) Have severe anaemia (haemoglobin < 70 g/L or < 7 g/dL) Have a history of allergy to chicken liver and/or eggs

Ages Eligible for Study
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Minimum Age: 19 Years
Maximum Age: 35 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: A total of 308 pregnant women will be recruited from 28 clusters (villages) and will be randomised to either intervention or control using a randomized sequence, stratified by villages with < 100 and ≥ 100 infants using block sizes of 2 and 4. Selected pregnant women from these villages will receive daily interventions in the form of 75 gram food products, made from chicken liver and chicken eggshells (Micronutrient-enriched Crackers/MEC) or placebo. The MEC and placebo will be given from 14 weeks gestation to 5 months' post-partum.
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Micronutrient Enriched Crackers (MECs)<br>Micronutrient Enriched Crackers (MECs) are a deep-fried snack product rich in iron, zinc, calcium, and vitamin A made from chicken liver and chicken eggshell powder. Consume daily, 75 gram/day, during pregnancy (from 14 weeks gestation to delivery) and lactation (from delivery to 5 months post-partum). | Dietary Supplement: Micronutrient Enriched Crackers (MECs)<br>* MECs are manufactured according to the Standard Operational Procedures which have been developed taking into account the Hazard Analysis and Critical Control Point (HACCP) to maintain quality and safety and ensure the Ready-to-eat MEC products are safe. Data on the micronutrient concentrations and any potential bacteriological (Salmonella sp is negative, Bacillus cereus, Enterobacteriaceae, and Coagulase positive streptococci level are considered safe) and chemical contaminants (Pb, Hg, Cd, As, and Sn are not detectable) in the MEC products have been obtained from analysis in the laboratory of Saraswanti Indo Genetech, which has been accredited by KAN LP-184-IDN with SNI ISO/IEC 17025: 2008. Laboratory analysis of MEC products will be repeated at the middle and the end of the RCT to check on the quality and safety of the MEC product.<br>* Other names: SISTIK;|
| Placebo Comparator: Placebo<br>Placebo Crackers are a deep-fried snack product made from the basic cracker ingredients (mainly wheat flour) with the addition of Pangium edule seeds to provide a color similar to the intervention product (MECs). Consume daily, 75 gram/day, during pregnancy (from 14 weeks gestation to delivery) and lactation (from delivery to 5 months post-partum). | Dietary Supplement: Placebo<br>* Placebo crackers are manufactured according to SOPs which have been developed taking into account the HACCP to maintain quality and safety and ensure the Ready-to-eat placebo products are safe. Data on the micronutrient concentrations and any potential bacteriological (Salmonella sp is negative, Bacillus cereus, Enterobacteriaceae, and Coagulase positive streptococci level are considered safe) and chemical contaminants (Pb, Hg, Cd, As, and Sn are not detected) in the placebo have been obtained based on the analysis in the laboratory of Saraswanti Indo Genetech, which has been accredited by KAN LP-184-IDN with SNI ISO/IEC 17025: 2008. Laboratory analysis of placebo samples will be repeated at the middle and the end of the RCT to check on the quality and safety of the placebo product.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Birth length | All measurements will be taken to the nearest millimetre (mm) using standardized techniques and trained anthropometrists using a portable infantometer (SECA 417, measuring range: 10-100 cm). The measurements will be made on nude infants and will be recorded in duplicate, or triplicate if the difference between the first and second measurement is more than the recommended range (i.e., 7 mm). | 24 hours after birth | 
| Attained linear growth and growth velocity | All length measurement will be taken to the nearest millimetre (mm) using standardized techniques by trained anthropometrists using a portable infantometer (SECA 417, measuring range: 10-100 cm) The measurements will be made on nude infants and will be recorded in duplicate, or triplicate if the difference between the first and second measurement is more than the recommended range (i.e., 7 mm). | 5 months (+/- 1 week) post partum | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Birth weight | All weight measurements will be taken to the nearest 10 grams using standardized protocols by trained anthropometrists using an electronic scale (SECA 334). The measurements will be made on nude infants and will be recorded in duplicate, or triplicate if the difference between the first and second measurement is more than the recommended range (i.e., 100g). | 24 hours after birth | 
| Maternal haemoglobin level | Blood will be taken by a trained personnel and hemoglobin concentration (g/dL) in the mother will be analysed by complete blood count in a certified laboratory (Prodia Laboratory; Sysmex XN-1000). | 35-36 gestational age and 5 months (+/- 1 week) post partum | 
| Maternal food intake | Weighed records will be collected by the mothers on 3 non-consecutive days: 2 weekdays and 1 weekend day using a digital scale with precision of 4 grams (Kitchen Scale EK3131). On the next day after each weighed food record has been completed by the mother, an experienced research assistant will conduct a 24-hour recall on the mother using telephone/online communication. Results from the weighed record and recall will be combined to determine maternal food intake, which will be converted into nutrient intakes based on the weight and nutritional value of each food using the Indonesian Food Composition Table. The Multiple Source Method (MSM) program will be applied to estimate individual usual intakes of energy and nutrients as well as the usual intake distributions for the study population. | 35-36 weeks gestational age, 2 months (+/- 1 week) and 5 months (+/- 1 week) post partum | 
| Status of breastfed infants (exclusive vs. non-exclusive) and breast milk volume | The deuterium dose-to-the mother technique will be performed to measure the volume of breast milk consumed by the infants and the status of breastfed infants. As much as 30 grams of Deuterium Oxide (D2O) are taken by the mother orally, which is then excreted into the breast milk consumed by the infant. Saliva sampling will be carried out according to protocol guidelines established by the International Atomic Energy Agency (IAEA; Human Health Series No. 7) with some adjustments to the number of days of sampling. Maternal and infant saliva samples will be taken on the 0th day before the mother is given D2O dose, and subsequently post-dose on day 2 or 3, day 8 or 9, and on day 13 or 14. A total of 2 mL of maternal and 1 mL of infant saliva will be collected on each sampling day. Saliva will be analyzed using Fourier Transform Infrared Spectrometry (FTIR), from which exclusive breastfeeding categorization and breast milk volume will be calculated using the Microsoft Excel Spreadsheet. | 5 months (+/- 1 week) post partum | 
| Breast milk micronutrient concentration | Full breast milk samples will be collected by mothers from one breast (washed with distilled, deionised water) using acid washed breast milk pumps (Medela Harmony Manual Breast Pump) into acid washed glass bottles. Mothers will be requested to refrain from breastfeeding on one breast at least 2 hours before the scheduled breast milk collection to allow for the collection of fore- and hindmilk. Breast milk micronutrient concentrations, including Na, Mg, P, K, Ca, Fe, Cu, Zn, Se will be analysed using ICP- MS Agilent 7900; Free Thiamine, TMP, and TPP using HPLC-FLD Agilent 1200; Cobalamin using Competitive Chemiluminescent Enzyme Immunase IMMULITE 1000; Riboflavin, FAD, FMN, NAD, panthothenic acid, pyridoxal, pyridoxine, biotin using UPLC-MS with a Waters ACQUITY UPLC I-Class system coupled to a Sciex 4500 triple quadrupole mass spectrometer; Performed retinol, Alpha-carotene, Beta-carotene, Beta-cryptoxanthin, Alpha- tocopherol, and Gamma-tocopherol using HPLC Agilent 1260. | 5 months (+/- 1 week) post partum | 
| Infant breast milk micronutrient intake | Data generated from the volume of infant's breast milk intake using Deuterium Oxide Dose-to- Mother Technique and analyzed breast milk micronutrient concentrations will be used to calculate breast milk micronutrient intakes of the infants at 5 months post-partum. | 5 months (+/- 1 week) post partum | 
| Maternal micronutrient status | Data generated from maternal micronutrient concentrations in serum (Ferritin, Soluble Transferrin Receptor (sTfR), Retinol-Binding Protein (RBP), Zn, and Se) and adjusted for inflammation status, where appropriate, using C-reactive protein and Alpha-1-acid glycoprotein will be used to assess maternal micronutrient status. The cutoffs used to define deficiency for each maternal biomarker will be as follows: adjusted serum ferritin, < 15 μg/L; adjusted sTfR, > 8.3 mg/L; adjusted zinc < 10.7 μmol/L; adjusted RBP < 1.20 μmol/L; and adjusted selenium < 0.82 μmol/L. | 35-36 weeks gestational age and 5 months (+/- 1 week) post partum | 
| Infant micronutrient status | Data generated from infant's serum micronutrient concentrations (Ferritin, sTfR, RBP, Zn, and Se) at 5 months post- partum, adjusted for inflammation status, where appropriate using C-reactive protein and Alpha-1-acid glycoprotein will be used to assess infant micronutrient status at 5 months post-partum. The cutoffs used to define deficiency for each biomarker among the infants will be as follows: adjusted ferritin, < 12 μg/ L, adjusted sTfR, > 8.3 mg/L; adjusted zinc < 9.9 μmol/L; adjusted RBP < 0.83 μmol/L (27); adjusted selenium < 0.82 μmol/L; vitamin B12 < 148 pmol/L. | 5 months (+/- 1 week) post partum | 
| Morbidity incidence rate of mothers and infant | The morbidity calendar for both mother and infant will be recorded by respondents independently and checked by research cadres once a week. The maternal morbidity calendar will be recorded over one month (for seizure, fever, headache, diarrhea, vaginal bleeding, cough, sore throat) at 14 weeks and 31-32 weeks of gestation, and 1 month and 4 months post-partum (for diarrhea, fever, cold, cough, vomit, ear infection, sore throat). The infant morbidity calendar will also be recorded over one month when the infant is 1 month and 4 months post-partum (for diarrhoea, fever, cold, cough, vomit, ear infection, sore throat). Digital thermometers will be provided to the respondents for self assessment of maternal and infant fever. | 14 weeks and 31-32 weeks gestational age, 1 month (+/- 1 week) and 4 months (+/- 1 week) post partum | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Chicken Liver, Eggshell, Crackers, Pregnancy, Lactating Mother, Indonesia