A Longitudinal Observational Study of a Powder-Based Supplement for a Future Synbiotic Trial in Breastfed Children From South Africa

Abstract

This study investigates the feasibility and acceptability of a powder-based supplement for breastfeeding HIV-exposed uninfected children to inform a larger trial (MIGH-T MO study). Ten mothers living with HIV and their children (6 weeks-20 months) at Tygerberg Hospital, Cape Town, South Africa, participated. The children received a daily supplement of potato maltodextrin mixed with expressed breast milk for 4 weeks, serving as a placebo control for the upcoming trial. Outcomes assessed included feasibility, acceptability, adherence, and health effects, evaluated at enrollment, during weekly calls, and at the 4-week visit. High acceptability was indicated by full enrollment of eligible participants, though there was some loss to follow-up (n = 3). Among the remaining participants, no major feasibility issues were found regarding procedures, product administration, adherence, tolerance, or health assessments. The study concludes that powder-based supplements are feasible and acceptable for breastfeeding HEU children, supporting the potential for larger studies using similar supplements.

Introduction

Children born to mothers living with Human Immunodeficiency Virus (HIV) have an increased risk of adverse health outcomes despite not acquiring HIV infections themselves. These children, who are HIV-exposed uninfected (HEU), have higher rates of mortality, respiratory, and gastrointestinal infections, and growth deficits even when the mother is on antiretroviral therapy (ART).^{1 -9} Whether observed differences in breastmilk composition between mothers with and without HIV can help explain the increased risk of adverse outcomes in HEU children is an area of active investigation.^{10 -12}

We have observed that maternal HIV status is linked to differences in breastmilk profile, including the composition of human milk oligosaccharides (HMO), and resulting changes in the infant gut microbiome profile.^{10 -12} HMOs are short-chain carbohydrates present in breastmilk and have been linked to improved child growth and reduced infectious morbidity.^13,14 We hypothesize that these differences in HMO profiles by maternal HIV status partly explain the increased adverse outcomes in HEU children, and that a supplement of specific HMOs (eg, 2’-fucosyllactose (2’FL)) given to breastfed HEU children will reduce these adverse outcomes. To test this hypothesis, we are currently conducting a proof-of-concept, randomized, placebo-controlled trial of a synbiotic intervention (2’FL and a Bifidobacterium infantis probiotics) in breastfed HEU children living in Worcester, South Africa. Details of the ongoing trial, “Mitigating Infectious Morbidity and Growth Deficits in HIV Exposed Uninfected Infants with Human Milk Oligosaccharides” (the MIGH-T MO study), can be found in the trial protocol manuscript. ¹⁵

While a well-designed randomized controlled trial (RCT) can serve as the gold-standard for determining the causal effect of a supplement, there can be major challenges in the conduct and interpretation of its results in instances of inadequate participant recruitment, follow-up or compliance with study procedures. ¹⁶ These challenges are especially relevant in studies of probiotic/prebiotic/synbiotic supplement in child populations as there are potential concerns related to mothers’ acceptance of the supplement and related study procedures, such as potential safety concerns or doubts about giving an unfamiliar supplement to their children. In addition, logistical aspects (eg, expressing breastmilk, mixing the supplement, feeding the supplement) of successfully administering a powder-based supplement to breastfeeding children along with details on adherence and morbidity outcome assessments require careful consideration. To address these concerns and avoid potential issues in the MIGH-T MO study and to ensure successful recruitment and conduct of the study procedures, we conducted a feasibility study prior to the initiation of the MIGH-T MO study.

In this feasibility study, 10 breastfeeding mothers and HEU children from Cape Town, South Africa were recruited to administer a powder-based product daily for 4 weeks. This product is the placebo as well as the base of the synbiotic supplement in the MIGH-T MO study. The aim of this feasibility study was to determine the acceptability and feasibility of administering a powder-based supplement, and to determine our ability to successfully assess adherence and study outcomes during and at the end of the study.

Materials and Methods

Feasibility Study Population

In this study, we recruited 10 mother-child pairs accessing care at Tygerberg Hospital, in Cape Town, South Africa between April 1st and December 30th, 2022. Inclusion criteria were postpartum women living with HIV (WHLIV) of at least 18 years of age, currently breastfeeding and intending to breastfeed for at least the next 6 weeks, with access to a cellular phone for study-related contact, and with HEU children between 1 and 24 months of age at enrollment. Exclusion criteria were children living with HIV, and severe maternal or child illness (eg, tuberculosis, major psychiatric, or neurological conditions). Study counselors involved in the community identified potential participants and convenience sampling was used to recruit WLHIV and their HEU children at the study site.

Feasibility Study Design and Procedures

For this feasibility study, HEU children were administered a powder-based product: potato maltodextrin, which is the placebo for the MIGH-T MO study and the base used to manufacture the synbiotic (ie, intervention for the MIGH-T MO study). This product was manufactured and packaged into daily-use sachets by International Flavors & Fragrances (IFF). Maltodextrin has been widely used as a placebo in multiple probiotic studies,^17,18 and is also an approved ingredient in infant formula.

At the enrollment visit at the Family Centre for Research with Ubuntu (FAMCRU), Tygerberg Hospital, the mothers administered the first day of supplement under supervision of the study staff. The staff supported and gave mothers directions on expressing breastmilk, mixing the supplement, and feeding it to their child. Additional training regarding breast hygiene and contamination prevention was also provided to them. During this visit, mothers were directly observed and supported to express breastmilk in a larger cup, then decanted into a smaller cup and mixed with one sachet of the supplement using a stirrer, and then cup fed from the smaller cup, with advice on positioning the child’s head to facilitate swallowing (Figure 1).

Figure 1.

Study supplement training material. (A) Daily-use sachets of supplement product that is, maltodextrin. (B) Stirrer and large medicine cup to collect expressed breastmilk. (C) Approximately 5 mL of expressed breastmilk was transferred from the large medicine cup to the smaller sized medicine cup (green), a stirrer was used to mix in the supplement, and the mixture was cup-fed to the child.

Maltodextrin powder was packaged in daily-use sachets (1.5 grams per day; 5.7 kcal, 0.11 grams sugar) and mothers were provided with sachets sufficient for 4 weeks of daily administration (one sachet per day), along with the cups and stirrer to take home. A diary and a pen were provided with pre-completed dates to serve as reminders for when to give their child the supplement, when to expect a telephone call from the study staff, and when to come in for their final in-person site visit. Mothers were also encouraged to note down any problems or issues they faced with administering the supplement in space provided in the diary.

After the enrollment visit (week 0), study participants had weekly telephone calls for weeks 1, 2, and 3. During the weekly calls, data on feasibility, acceptability, adherence, and outcome assessment (ie, child illnesses) were collected using a standard questionnaire. Furthermore, these telephones calls also served to troubleshoot potential issues with the supplement administration or study procedures. Telephone calls were restricted to three attempts to make allowance for mothers not being able to answer their telephones. At week 4, study participants had their last in-person visit at the study site. At this visit, similar data on feasibility, acceptability, adherence, and outcomes were collected. Mothers were also asked to provide feedback on their overall study experience and make suggestions to improve any aspects of the study design. Mothers were compensated, in the form of vouchers, 350 rands (~$22) for in-person visits and 50 rands (~$3) for telephonic visits.

During all interactions with the mothers, the study staff were advised to take their time talking to the participants and to be cognizant of the mother’s time and comfort in answering questions, especially over telephone calls. To make the mothers familiar with the telephone number and the process of receiving calls from the study team, a telephone call was made in the presence of the mothers while they were at the site. To further facilitate relationship-building between study staff and mothers, follow-up telephone calls were made by the same research assistant who initiated the mother’s in-person enrollment visit.

Acceptability was determined by the number of mothers who were screened, met the eligibility criteria, and ended up joining the study without serious concerns around administering the supplement to their children. Feasibility was assessed based on the number of mothers who successfully administered the supplement and whether they faced challenges in administering the product to their children.

To assess adherence, mothers were asked to keep the empty (ie, used) sachets and bring them to their last study visit. As part of the weekly telephone call, they were also queried on missed doses. In addition, the diary card was reviewed at the week 4 visit, to note date and time of administering the supplement and any concerns they had recorded.

During the study calls and visit, data on child health outcomes, which included healthcare provider visits and any potential illnesses (fever, diarrhea, respiratory illness, or others), along with data on symptoms of intolerance to the placebo (eg, excessive flatulence, vomiting, irritability, frequency of stool etc.), were collected using a standard questionnaire.

Feasibility Study Goals and Analysis

The primary goal was to determine the feasibility and acceptability of study supplement administration. Two indicators were used: (1) among the participants who were eligible, those who agreed to give the supplement to their children, and (2) number of participants who successfully administered the supplement to their children. Further, another goal of this study was to determine the adherence to study supplement, which was analyzed based on the number of doses administered to the child. An additional goal was to determine the feasibility of collecting child health outcome data. This was analyzed based on the ability and response rate to collect illness data in the weekly calls and final study visit.

As this was a feasibility study with mainly qualitative data, we present descriptive and qualitative data. For the study to be considered feasible and acceptable, we expected the majority of mothers to accept this supplement for their child and for the majority of the children to have been administered the supplement successfully.

Ethics

The Human Research Ethics Committee at Stellenbosch University and the Institutional Review Board at Columbia University approved this study. All methods were performed in accordance with local guidelines and regulations. All women participating in the study provided written informed consent for themselves and their children, obtained in person and in their preferred language (Afrikaans or isiXhosa).

Results

Study Population

A total of 10 adult breastfeeding (some exclusive breastfeeding and others mixed feeding) WLHIV and their HEU children were enrolled in this feasibility study from April 2022 to May 2022. The mean age of the mothers was 32 years (range: 22-39), and mean parity was 2.2 (range: 1-4). Of the 10 HEU children enrolled, 7 were girls and 3 boys, ranging from 6 weeks to 20 months of age.

Feasibility and Acceptability

Recruitment, Enrollment, and Acceptability

FAMCRU recruiters identified community members who would meet the inclusion criteria, and they were invited to attend screening at our site. All potential participants who were screened met the eligibility criteria. All the mothers who met the eligibility criteria consented and were enrolled, indicating acceptance of the study supplement and procedures for their children (Figure 2).

Figure 2.

Flow diagram for the feasibility study.

Retention

Seven participants completed most of the study procedures (ie, attended the weekly telephone calls and the last week site visit). Of these 7 participants, 6 participants completed all telephone calls (and the other participant missed 1 telephone call), and all 7 completed the final visit (Figure 2). Three participants came in for their first visit only and were thereafter lost to follow-up. One did not have a reliable telephone and could not be contacted after their initial study visit. For the other 2 participants, a possible reason for loss to follow up was a lack of interest in the study and study procedures.

Study product administration

At their enrollment visits, all 10 mothers indicated acceptance of the supplement and were able to administer the supplement to their child successfully at the study site. Of the 7 mothers who remained on the study, none reported having trouble expressing breastmilk at home. Five of the seven children finished most of the milk and powder mix on all days. Of the 2 children who did not, 1 child did not finish most of the milk and powder mix on 2 days.

The mothers did not experience major challenges in administering it to their children. One of the mother tasted the product and noted it as sweet. A few challenges that the mothers experienced included being away from their child due to work or other reasons which posed a challenge in administering the supplement. Other aspects that were challenging included the children’s resistance to drinking the milk with the powder; one of the mothers reported that her child did not seem to like the powder and had to be coerced into taking it, and another mother reported that her child was uncooperative in taking the powder when sick or crying.

Effectiveness of telephone calls

Weekly telephone calls to mothers were made to collect data on their child’s health, challenges or concerns experienced when administering the supplement, and feedback for the study. Two mothers answered their telephone on the first attempt for all calls. Others needed 2 or 3 attempts for contact but did answer their telephones and completed the questionnaire. One mother was reached through a secondary telephone number.

At their last visit, mothers were asked whether the weekly telephone calls were helpful to answer their questions or concerns and 100% of them answered “yes,” citing reasons ranging from having questions about the supplement and their child’s health answered, to the telephone calls serving as reminders to give their child the supplement.

Outcome Assessments:

Child Health Outcome Assessment

Over the 4 weeks, none of the mothers reported taking their child to visit a doctor or healthcare provider for any symptoms or illness (Table 1). Additionally, none of the children experienced diarrhea, one of the seven children experienced fever (attributed to teething and not the supplement), and three children had respiratory illnesses (cough and cold). One child experienced pimples and constipation for 2 days.

Table 1.

Outcome Assessments of the Feasibility Study.

	Number of participants
Child health outcome assessment
Doctor/healthcare visit	0
Diarrhea	0
Fever	1
Respiratory illness	3
Other*	1
Child tolerance assessment
Flatulence	1
Spit-up	2
Vomit	1
Irritability	2
Sleepless nights	1
Colic or stomach cramps	0
Passed stool more than 3 times in one day	0
Adherence assessment
Gave placebo every day	5
Followed guideline of feeding only one sachet per day	5
Brought in sachets to the study site	7

*

One child experienced pimples and constipation.

Adherence assessment

All 7 mothers who stayed on the study had high adherence in giving their child the supplement. Mothers were asked if they gave their child the placebo every day, all mothers except two answered “yes” (Table 1). One of the mothers who said “no,” missed 3 days for reasons likely not related to study products; her child experienced pimples and constipation for 2 days that resolved and did not re-occur after re-initiation of the supplement. Regardless, all mothers on the study gave their children >85% of the supplement between the first and last visit.

Supplement adherence was also assessed in terms of the number of opened/used sachets. Mothers were asked to bring in all sachets (both used and unused) at their last study visit (Table 1). Based on the sachets brought in, 5 of 7 mothers gave their child the powder every day and 2 mothers missed a few doses.

In terms of adhering to supplement guidelines of feeding only one sachet of powder per day, two mothers reported mixing more than one sachet in their expressed breastmilk (Table 1).

Tolerance assessment

Overall, the supplement was well-tolerated by the children with only minor issues reported in this age group. Over the 4 weeks, 1 out of 7 children experienced “a lot” of flatulence prior to one of the telephone calls (Table 1). Two children experienced “a lot” of spit-up at one timepoint, one of whom concurrently experienced “a lot” of vomit and “a bit” of irritability. Another child experienced “a lot” of irritability and “sometimes” sleepless nights during one of the study weeks, and only sleepless nights “sometimes” during another study week. No children experienced colic or stomach cramps and none of the children passed stool more than 3 times in a day in the 3 days prior to their post-supplement telephone calls/visit.

Discussion

Our feasibility study of a powder-based supplement administered to breastfeeding children in South Africa was acceptable and feasible. Breastfeeding mothers were accepting of the supplement for their children and any concerns that they had were easily addressed by the study staff. There were no major challenges in administering the powder-based supplement to their children, and there was strong participant adherence to study procedures and supplement. Data on child health status and tolerability were also successfully obtained through site visits and telephone calls. However, there was some loss to follow-up in this study. Overall, our results suggest that a future study of powder-based supplement (eg, probiotic, prebiotic, or synbiotic) for breastfeeding children in similar settings will likely be acceptable and feasible.

All women screened and eligible to join the study were enrolled, speaking to the high acceptability of the proposed study and supplement. After joining the study, the mothers did not have any prolonged acceptability concerns with regards to the supplement and study procedures. Any initial reservations that they had were either addressed by the study staff or were resolved on their own (eg, child’s constipation resolved and did not re-occur upon re-starting the study product). The concerns raised were either unrelated to the study product or were due to misunderstandings that were cleared up. For example, some mothers wanted to taste the product themselves first, speaking to the importance of manufacturing extra sachets of products to address such concerns along with training needs.

With regards to the feasibility of administering a powder-based supplement and following the study procedures, all mothers at the initial visit and the rest who were not lost-to-follow-up at the subsequent visits, reported being able to follow them without major challenges or problems. Demonstrating and helping mothers with administering the first dose at the study site was helpful for mothers to troubleshoot and have their questions answered. Our additional training related to breastmilk expression, breast hygiene and preventing contamination underlined the need to educate and support the mothers for successful feasibility.

There was also training for the mothers to maintain breast hygiene including addressing questions related to cleaning breasts after expressing milk and cleaning cups properly to prevent contamination. It also helped to keep breast pads in the study room to assist mothers during their in-person visits.

Among the participants that remained in the study, there was high adherence to the supplement. This can be explained partly to the weekly telephone calls that partially served as reminders as well as diary cards that outlined the time and dates for study product supplement for ease of following. Compliance to study procedures and adherence to the supplement is crucial in an RCT and an objective method to quantify this in a powder-based clinical trial is to collect empty sachets. While two mothers on this study discarded their sachets, for future trials it is important to provide consistent reminders to mothers to not discard empty sachets and return them to the study staff.

Collection of outcome data on child health and tolerability was primarily done through weekly telephone calls. It was feasible to collect this data over telephone calls without difficulty. The ease of telephone calls to collect data makes it a practical mode for ongoing data collection in between study visits to supplement on-site data collection.

Recruitment and retention were dependent on establishing trust between the research institution and participants through building a relationship with the research assistant, providing clear instructions and planning, including considerate call scheduling. During recruitment, study staff were advised to take their time during the consenting and screening phase resulting in all women joining the study among those who were screened and eligible. Diary cards were also useful in structuring the telephone call and follow-up visits. Another reason that likely contributed to study enrollment and retention is financial compensation for the participant’s time on the study. Similar recruitment strategies that were successful will also be used in the MIGH-T MO study.

There was some loss to follow-up in this feasibility study. A likely reason is the relatively short duration of the study and no obvious benefit to the child considering this was a “placebo study.” We anticipate higher retention in the main study as there may be prospect for direct benefit to the child with the synbiotic supplement and additionally, a prolonged connection with the study staff could help with care for the child.

One challenge related to retention and adherence to supplement experienced in this study, and potentially expected to arise in the main trial, is that of mothers returning to work and leaving their children with caretakers. For this reason, in the main study, it is important to discuss with mothers plans for if and when they will be away from their children during the study and advise them on ways to continue the supplement in their absence for example, the powder and expressed breastmilk or formula milk can be given to the caretaker to feed to the child.

Overall, the information learned from this study has been helpful to inform the ongoing MIGH-T MO trial procedures. For example, we observed that breastfeeding mothers with HIV are not averse to expressing breastmilk and joining a trial with a powder-based supplement. We also learned that the administration of the supplement was feasible and acceptable. We also noted a few challenges that would need to be taken into account (eg, a father throwing away the sachets in error, so important to involve the father as well; approaches to improve retention, including frequency of phone calls, and potential home visits). Finally, we also confirmed the utility of diary cards, sachet counts and telephonic calls for outcome assessment and improvement in adherence.

Despite the valuable information obtained for the future MIGH-T MO trial and similar trials of probiotics in children, our study has some limitations. One limitation is the limited sample size. While this sample size was informative for the main goals to assess the acceptability and feasibility, the sample size was more limited for the secondary goal of the feasibility of assessing infectious morbidity. Our loss-to-follow-up was also higher than expected but as detailed above some of the issues are likely to be resolved with the design of the main trial. Finally, it remains to be determined whether the feasibility and acceptability will be similar with a bigger sample of mother-child pairs, and administration of the supplement for a longer time (ie, 5 months in MIGH-T MO as compared to 1 month for this feasibility study).

This study showed that a powder-based supplement for breastfeeding children in South Africa was acceptable and feasible. Overall, based on the response to this study, we do not anticipate any other major concerns or challenges with regards to the MIGH-T MO study. We also expect these findings to be useful and likely generalizable to other probiotics/prebiotics/synbiotics studies of breastfeeding children in similar settings and in other relevant populations (eg, mothers without HIV from similar settings).

Conclusion

In conclusion, our study found that administering a powder-based supplement to breastfeeding children in South Africa was both acceptable and feasible. The supplement was well-received by mothers, who had few concerns that were easily addressed. There were no major challenges in administering the supplement, and participants adhered well to study procedures. While some participants were lost to follow-up, data on child health and tolerability were successfully obtained through site visits and telephone calls. Overall, our findings suggest that a future study of powder-based supplements, such as probiotics, prebiotics, or synbiotics, for breastfeeding children in similar settings is likely to be feasible and well-received.