Safety and Efficacy of Infant Formulas Supplemented With Pre- and Probiotic(s)

Study Overview
=================
Brief Summary
-----------------
This is a randomized, controlled, multicenter, double-blind study of healthy term infants. The primary objective of the trial is to demonstrate the safety of a a starter infant formula supplemented with pre- and probiotic(s) by comparing the growth of infants randomized to the experimental formula versus the control formula from enrolment to 4 months of age.

Detailed Description
-----------------
This is a randomized, controlled, multicenter, double-blind study of healthy term infants, consisting of two randomized formula-fed arms (control and experimental formulas) and a non-randomized breast-fed reference group. The population under investigation are healthy infants aged ≤14 days at enrollment. The planned sample size for formula-fed infants is 236 (118 per study group). A non-randomized breastfed reference group of 90 healthy, term, exclusively breastfed infants up to 4 months will also be enrolled. Study formulas are administrated orally, ad libitum, from enrollment until 15 months of age. The primary objective of the trial is to demonstrate the safety of a starter infant formula supplemented with pre- and probiotic(s) by comparing the growth (weight gain, g/day) of infants randomized to the experimental formula versus the control formula from enrolment to 4 months of age. In addition fecal microbiome, fecal metabolic profile, fecal markers of immune and gut health, blood markers of immune health (in a subset of 60 infants/group), GI tolerance, bone index (subset of 40 infants/group), other anthropometric measurements, dietary pattern and infant illness and infection outcomes will be assessed/measured.

Official Title
-----------------
Safety and Efficacy of Starter Infant Formula, Follow-up Formula and Growing-up Milk Supplemented With Pre- and Probiotic(s): a Double-blind, Randomized, Controlled Trial

Conditions
-----------------
Healthy Infants

Intervention / Treatment
-----------------
* Other: Experimental formulas (EF)
* Other: Control formulas (CF)
* Other: Breast feeding (BF)


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Evidence of personally signed and dated informed consent document indicating that the infant's parent(s)/ legally accepted representatives LAR have been informed of all pertinent aspects of the study. Infants whose parent(s)/LAR have reached the legal age of majority in the countries where the study is conducted. Infants whose parent(s)/LAR are willing and able to comply with scheduled visits, and the requirements of the study protocol. Infants whose parent(s)/LAR are able to be contacted directly by telephone throughout the study. Infants must meet all of the following inclusion criteria to be eligible for enrollment into the study: Healthy term infant (≥37 weeks of gestation) At enrollment visit, post-natal age ≤14 days/0.5 months Birth weight ≥ 2500g and ≤ 4500g. For formula-fed groups, infants must be exclusively consuming and tolerating a cow's milk infant formula at time of enrollment and their parent(s)/LAR must have independently elected, before enrollment, not to breastfeed. For the breastfed group, infants must have been exclusively consuming breast milk since birth, and their parent(s)/LAR must have made the decision to continue exclusively breastfeeding until at least 4 months of age. Exclusion Criteria: Infants with conditions requiring infant feedings other than those specified in the protocol. Infants who have a medical condition or history that could increase the risk associated with study participation or interfere with the interpretation of study results, including: Evidence of major congenital malformations (e.g., cleft palate, extremity malformation) Suspected or documented systemic or congenital infections (e.g., human immunodeficiency virus, cytomegalovirus, syphilis) Previous or ongoing severe medical or laboratory abnormality (acute or chronic) which, in the judgment of the investigator, would make the infant inappropriate for entry into the study. Of note, children who are normally healthy but at the time of enrollment suffering from acute illness in a minor condition which are common in childhood and do not require some of the exclusionary medication mentioned below can be enrolled. Infants who are presently receiving or have received prior to enrollment any of the following: medication(s) or supplement(s) which are known or suspected to affect the following: fat digestion, absorption, and/or metabolism (e.g., pancreatic enzymes); stool microbiota and characteristics (e.g., oral or systemic antibiotics, glycerin suppositories, bismuth-containing medications, docusate, Maltsupex, or lactulose); growth (e.g. insulin or growth hormone); gastric acid secretion. Currently participating or having participated in another clinical trial since birth. Subjects or subjects' parent(s) or legal representative who are not willing and not able to comply with scheduled visits and the requirements of the study protocol

Ages Eligible for Study
-----------------
Minimum Age: 0 Days
Maximum Age: 14 Days

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Double-blind, randomized, controlled trial plus a non-randomized breastfed reference group
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Experimental formulas (EF) group<br>Starter infant formula, follow-up infant formula and growing-up milk (partially hydrolyzed bovine whey protein) supplemented with pre- and probiotic(s) | Other: Experimental formulas (EF)<br>* First age formula administered orally ad libitum until 6 months of age, switch to second age formula until 12 months and finally to growing-up milk from 12 to 15 months<br>|
| Active Comparator: Control formulas (CF) group<br>Starter infant formula, follow-up infant formula and growing-up milk (partially hydrolyzed bovine whey protein) not supplemented | Other: Control formulas (CF)<br>* First age formula administered orally ad libitum until 6 months of age, switch to second age formula until 12 months and finally to growing-up milk from 12 to 15 months<br>|
| Active Comparator: Breastfed (BF) group<br>Breast milk | Other: Breast feeding (BF)<br>* Exclusive breast feeding up to 4 months<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Weight | Weight gain measured as mean daily weight gain in g/day | From baseline (≤14 days) to 4 months of age | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Bifidobacteria abundance | Bifidobacteria abundance | At 90 days (3 months of age) | 
| Fecal microbiome | Overall fecal microbiota composition, diversity, different bacteria taxa and microbiota community types assessed using next generation sequencing (NGS) technology | Stool sample collected at ≤14 days (baseline), 3, 6, 12 and 15 months of age | 
| Fecal metabolic profile: fecal pH | Fecal pH | Stool sample collected at ≤14 days (baseline), 3, 6, 12 and 15 months of age | 
| Fecal metabolic profile: fecal organic acids | Fecal organic acids (such as, but not restricted to lactate, including indole-lactate, L- and D-lactate, propionate, butyrate, acetate, valerate, and total fecal organic acids) | Stool sample collected at ≤14 days (baseline), 3, 6, 12 and 15 months of age | 
| Fecal markers of immune health and gut barrier | Fecal markers of immune health and gut barrier such as total secretory IgA (sIgA), lipocalin-2, calprotectin, and α-1-antitrypsin assessed by ELISA. | Stool sample collected at ≤14 days (baseline), 3, 6, 12 and 15 months of age | 
| Fecal cytokine profile | Fecal cytokine profile (such as but not restricted to: IL-6, IL-8, IL-1b, IL-22, IFN-γ) using multiplex assays | Stool sample collected at ≤14 days (baseline), 3, 6, 12 and 15 months of age | 
| Blood markers of immune health | Vaccine specific antibodies assessed by ELISA and Immuno-phenotyping in a subset of 120 infants (60/group) | At 4 months of age | 
| GI-related behavior: stool frequency | Stool frequency recorded via the GI Symptom and Behavior Diary | Retrospective 1-day (at baseline) and prospective for 3 days prior to 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| GI-related behavior: stool consistency | Stool consistency recorded via the GI Symptom and Behavior Diary | Retrospective 1-day (at baseline) and prospective for 3 days prior to 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| GI-related behavior: incidence of spitting | Incidence of spitting recorded via the GI Symptom and Behavior Diary | Retrospective 1-day (at baseline) and prospective for 3 days prior to 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| GI-related behavior: incidence of flatulence | Incidence of flatulence via the GI Symptom and Behavior Diary | Retrospective 1-day (at baseline) and prospective for 3 days prior to 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| GI-related behavior: crying time | Crying time via the GI Symptom and Behavior Diary | Retrospective 1-day (at baseline) and prospective for 3 days prior to 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| GI-related behavior: sleep time | Sleep time via the GI Symptom and Behavior Diary | Retrospective 1-day (at baseline) and prospective for 3 days prior to 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| GI-related behaviour: volume of formula consumed | Volume of formula consumed at each feeding or the number of breast milk feedings recorded via the GI Symptom and Behavior Diary | Retrospective 1-day (at baseline) and prospective for 3 days prior to 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| Infant Gastrointestinal Symptom Index | GI symptoms via the Infant Gastrointestinal Symptom Questionnaire (IGSQ-13) | At baseline, 1, 2, 3, 4, 6, 9, 12 and 15 months of infant age | 
| Bone index | Bone index measurement will be conducted using a non-invasive and radiation-free ultra-sound sonometer in a subset of 80 children (40/group) | At baseline, 3, 6, 9, 12 and 15 months of infant age | 
| Additional growth parameters: weight | Weight in grams and corresponding weight-for-age Z-score according WHO growth standards | At infant age ≤14 days (baseline), 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| Additional growth parameters: length | Length in centimeters and corresponding length-for-age Z-score according WHO growth standards | At infant age ≤14 days (baseline), 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| Additional growth parameters:head circumference | Head circumference in centimeters and corresponding head circumference-for-age Z-score according WHO growth standards | At infant age ≤14 days (baseline), 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| Additional growth parameters: Body Mass Index | BMI (kg/m2) and corresponding BMI-for-age Z-score according WHO growth standards | At infant age ≤14 days (baseline), 1, 2, 3, 4, 6, 9, 12 and 15 months of age | 
| Dietary pattern | Data collected using a food frequency questionnaire including key food groups for infants and young children | At infant age 6, 9, 12 and 15 months | 
| Absenteeism (infant and parent) | Time away from daycare (infant) or work (parent) will be recorded during occurrences of illness / infection using a calendar-based electronic Infant Illness Diary (IID) | Data collected continuously from enrollment until 15 months of age |