Brain Probiotic and LC-PUFA Intervention for Optimum Early Life

Study Overview
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Brief Summary
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Probiotics is suggested to play several roles in promoting health, including alleviating disease symptoms, protection against atopic disease, and modulating the immune system by improving the beneficial gut microbiota colonization. The discovery of the gut microbiota-brain axis suggested that there is a reciprocal influence between the brain and the gut through a constant communication. This bi-directional axis enables signals to be transferred from brain to influence sensory, motor, and secretory modalities of the GI tract, also permits signal from the gut to influence brain function. The establishment of intestinal microbiota during early neurodevelopmental period suggests the colonization and maturation of gut microbiota may influence brain development. Several studies have shown there is an association between shifts in the gut microbiota composition in children with neurodevelopmental disorders. This study aims to investigate how maternal probiotic + LC-PUFA supported with government program supplements, healthy eating, and psychosocial stimulation could affect fetal brain development and later child brain functions and cognitive development. Intervention would be delivered to pregnant women for 9 months, starting at the end of second trimester of gestational period.

Detailed Description
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Health and well-being at all ages is one of the goal set in the Sustainable Development Goals. Starting as early as possible has been considered to be an effective strategy for better investation in achieving healthy population. Therefore, the prevention and promotion of health and well being is starting to target population at younger age, starting as early as possible. Accordingly, the early life period of individuals has been considered as a critical period, especially in terms of the brain and cognitive development. The phases of brain development starts very early, starting from the fetal development in the uterus. The development process extends from early in the beginning of fetal development and lasted to the end, finishing last. The brain undergoes a period of rapid growth during the last trimester of fetal life and the first 2 years of childhood. Therefore, quality of pregnancy as well as quality of early life is important to the fetal brain development as well as later child brain function and cognitive development. In line with that notion, there are many studies suggesting that gut microbiota could affect CNS development through several ways, i.e. alteration of microbial composition, activation of immune system, changes in signaling via neural pathways, affecting tryptophan metabolism, modulating gut hormonal response and affecting hormonal signaling pathway, and releasing metabolites that could stimulate sympathetic nervous system. In particular, these studies have found bi-directional communication between the brain and the gut microbiota, referred to as the microbiota-gut-brain axis. The animal study showed that the gut microbiota regulates the development and function of the brain. Unfortunately, the study on human was still lacking. This study is a randomized clinical trial (RCT) and placebo parallel controlled study, followed by a follow-up study at 2 years old. The research will be conducted in eight public hospitals / health care facilities in Indonesia, Jakarta. In light of COVID-19 outbreak, if face-to-face activities are permitted by (1) national government (Indonesian Ministry of Health), (2) local government (DKI Jakarta), (3) the university, (4) Data Safety Monitoring Board, and (5) by consent of the subject, then the activities need to be strictly adjusted with the COVID-19 prevention measures for both personnel and subjects. All personnel and subjects who will be involved in the activities are required to fill out the COVID-19 symptom screening form prior to the visit. Some adjustments for the project field implementation have been conducted during the outbreak, including: Following Good Clinical Practice, for the safety of the subjects and all the team members, we are now ensuring that the subjects gain benefits from their involvement in the BRAVE project by implementing routine COVID-19 screening, providing adequate PPE for the fieldworkers, and educating them about the prevention measures. Supplement delivery: Because we could not visit to the houses anymore due to staff restriction regulations, the bottles of the supplement are delivered using online motorcycle taxi services, and this includes the weighing scale for monthly monitoring. We have also developed a protocol to ensure the safety of supplement bottle transfer from the research personnel to the motorcycle taxi driver, and from the driver to the mothers, including safe distancing and disinfection procedures. We will also educate, provide a thermometer for self-temperature screening and provide the disinfectant to the mothers. Outcome assessment: As per March 19, MRI assessment and blood sample collection remained implemented at a non-COVID-19 referral hospital and laboratory, with strict safety procedures for the subjects and personnel. For mothers who do not feel comfortable visiting the hospital/laboratory, they are free to refuse these procedures. Compliance: Online system to promote and assess compliance. To maintain the quality, we cross-check mothers' activities by online assessment, interactive short message service (sms), and phone calls. New Subject Recruitment are less priority right now or potentially stop for the time being until the situation is getting better.

Official Title
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Promotion of Maternal Gut Microbiota and Psychological Stimulation on Child Cognitive Development at 6 Months of Age

Conditions
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Maternal Exposure, Health Behavior, Infant Development, Child Development

Intervention / Treatment
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* Dietary Supplement: Probiotics and LC-PUFA (480 mg DHA)
* Dietary Supplement: Placebo probiotics and control LC-PUFA (120 mg DHA)
* Behavioral: Psychosocial stimulation and healthy eating education


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Each pregnant woman must meet all of the following criteria to be enrolled in this study: 1. Indonesian pregnant women in the 2nd trimester of gestational period 2. healthy pregnancy (as measured by hemoglobin level, pregnancy status, pregnancy history) 3. Having a normal blood pressure 4. Planning to stay in the study area until the child is 6 months old 5. Willing to sign informed consent 5. Having a legally acceptable representative who is capable to understand the informed consent document and providing consent on the subject's behalf Exclusion Criteria: Each pregnant women meeting any of the following criteria will be excluded from the study: Having foreign objects in the body due to trauma, artificial heart value, metal objects or ferromagnetic (plate, screw, clip, prosthetic), and electronic device (pacemaker, cochlear implant, insulin pump), and being claustrophobic Having history of previous gestational diabetes or been diagnosed to have gestational diabetes Having history of type 1 and type 2 diabetes Severe anemia Inclusion Criteria for Follow-up at 24 months: Child age above 24 months from the BRAVE intervention project Having a legally acceptable representative who is capable to understand the informed consent document and providing consent on the subject's behalf Exclusion Criteria for Follow-up at 24 months: 1. Child being hospitalized during the study/data collection

Ages Eligible for Study
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Minimum Age: 20 Years
Maximum Age: 40 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: Combination product: Probiotics and LC-PUFA The product will be given to 314 pregnant women, 157 pregnant women as an intervention group, and 157 pregnant women as a control group
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention<br>150 pregnant women will be given Probiotics and 480 mg DHA, psychosocial stimulation, and healthy eating education | Dietary Supplement: Probiotics and LC-PUFA (480 mg DHA)<br>* Probiotics and LC-PUFA (480 mg DHA)<br>Behavioral: Psychosocial stimulation and healthy eating education<br>* Psychosocial stimulation and healthy eating education<br>|
| Placebo Comparator: Control<br>150 pregnant women will be given placebo probiotics and 240 mg DHA, psychosocial stimulation, and healthy eating education | Dietary Supplement: Placebo probiotics and control LC-PUFA (120 mg DHA)<br>* Placebo probiotics and control LC-PUFA (120 mg DHA)<br>Behavioral: Psychosocial stimulation and healthy eating education<br>* Psychosocial stimulation and healthy eating education<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Total brain volume | measured in parenchymal and cortical regions | 1 year | 
| Fetal brain development | Myelination index | 1 year | 
| Child cognitive at 4 months of age | Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III); a higher score indicates better performance | 1 year | 
| Brain function at 4 months of age | Brainstem Evoked Response Audiometry (BERA) | 1 year | 
| Eye tracking tasks at 6 months of age | Visual paired comparison memory task and Infant Orienting with Attention task at 4 months of age | 1 year | 
| Child cognitive at 6 months of age | Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III); a higher score indicates better performance | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Mother depression scale | Mother's Depression Test; a lower score indicates better performance | 1 year | 
| Birth weight | Baby weighing scale | 4 month | 
| Child's Growth | Change in weight-for-age z-score | 6 months | 
| Child's linear growth | Change in Length-for-age z-score | 6 months | 
| Head circumference | Change in Head-circumference-for-age | 6 months | 
| Child nutritional status | Change in weight-for-length z score | 6 months | 
| Quality of interaction with parents | Maternal involvement using HOME inventory questionnaires | 1 year | 
| Maternal blood micronutrient & macronutrient status | Zinc, iron, folate, omega-3 blood level | 1 year | 
| Incidence of gestational diabetes | Based on blood glucose assessment | 1 year | 
| Incidence of pre-eclampsia | Diagnosed by physician | 1 year | 
| Incidence of preterm birth | Gestational age | 4 month | 
| Mother's dietary quality | actual dietary intake, dietary pattern and quality | 1 year | 
| Maternal fecal microbiota composition | Microbiota composition by S16rRNA analysis | 1 year | 
| Child fecal microbiota composition | Microbiota composition by S16rRNA analysis | 4 months | 
| Maternal omega-3 level in breast milk at 4 months of age | Omega-3 level assessment using Gas Chromatography-Mass Spectrometry | 1 year | 
| Human milk oligosaccharides at 6 months of age | 2-FL HMO assessment in breast milk | 1 year | 
| Maternal glucagon-like peptide-1 (GLP-1) profile | GLP-1 assessment using enzyme-linked immunosorbent assay | 1 year | 
| Maternal peptide-YY (PYY) profile | PYY assessment using enzyme-linked immunosorbent assay | 1 year | 
| Maternal fecal short chain fatty acids (SCFAs) | SCFAs analysis using Gas Chromatography-Mass Spectrometry | 1 year | 
| Child fecal short chain fatty acids | SCFAs analysis using Gas Chromatography-Mass Spectrometry | 1 year | 
| Post-partum weight retention | Monthly changes in maternal weight | 1 year | 
| Maternal weight circumference | Post-partum monthly changes in weight circumference | 1 year | 
| Gestational weight gain | Changes in maternal height throughout pregnancy period | 1 year | 
| Head circumference | Change in Head-circumference-for-age | 25 months | 
| Mid-Upper Arm Circumference | Change in Mid-Upper Arm Circumference | 25 months | 
| Toddler Body Weight | Toddler weighing scale | 25 months | 
| Toddler Height | Toddler height measurement | 25 months | 
| Mother Body weight | Mother's body weight | 1 year | 
| Mother Depression Test | Mother depression score | 1 year | 
| Mother Quality of Life | Mother quality of life score | 1 year | 
| Maternal History of COVID-19 during follow-up | Frequency of COVID-19 case during the follow-up period | 2 years | 
| Maternal Occurrence of COVID-19 during intervention period | Frequency of COVID-19 case during the intervention period | 1 year | 
| Child cognitive at 25-28 months of age | Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III); a higher score indicates better performance | 1 year | 
| Eye tracking tasks at 25-28 months of age | Visual paired comparison memory task and Infant Orienting with Attention task at 24 months of age | 1 year | 
| Mother Height | Mother's height | 1 year | 
| Mother Fat Percentage | Mother's fat percentage | 1 year |