Clinical Trials Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Pathophysiol. Feb 15, 2016; 7(1): 160-170
Published online Feb 15, 2016. doi: 10.4291/wjgp.v7.i1.160
Hypoallergenic formula with Lactobacillus rhamnosus GG for babies with colic: A pilot study of recruitment, retention, and fecal biomarkers
Nicole Y Fatheree, Yuying Liu, Michael Ferris, Melissa Van Arsdall, Valarie McMurtry, Marcela Zozaya, Chunyan Cai, Mohammad H Rahbar, Manouchehr Hessabi, Ta Vu, Christine Wong, Juleen Min, Dat Q Tran, Fernando Navarro, Wallace Gleason, Sara Gonzalez, J Marc Rhoads
Nicole Y Fatheree, Yuying Liu, Melissa Van Arsdall, Juleen Min, Dat Q Tran, Fernando Navarro, Wallace Gleason, Sara Gonzalez, J Marc Rhoads, Department of Pediatrics, the University of Texas Health Science Center at Houston Medical School, Houston, TX 77030, United States
Chunyan Cai, Mohammad H Rahbar, Manouchehr Hessabi, Biostatistics/Epidemiology/Research Design Core, Center for Clinical and Translational Sciences, the University of Texas Health Science Center at Houston, Houston, TX 77030, United States
Chunyan Cai, Mohammad H Rahbar, Manouchehr Hessabi, Division of Epidemiology, Human Genetics and Environmental Sciences, the University of Texas School of Public Health at Houston, Houston, TX 77030, United States
Michael Ferris, Valarie McMurtry, Marcela Zozaya, Department of Pediatrics, Louisiana State University Health Science Center and the Research Institute for Children, New Orleans, LA 70112, United States
Ta Vu, Christine Wong, Investigational Drug Services Pharmacy, Memorial Hermann Hospital, Houston, TX 77030, United States
Author contributions: The first two authors contributed equally to this work and are both considered first authors. Fatheree NY, Liu Y, Rahbar MH and Rhoads JM were integral to the clinical protocol and study design; Fatheree NY, Van Arsdall M, Navarro F, Gleason W and Rhoads JM collected clinical data; Gonzalez S supported research team by providing nutritional expertise; Liu Y provided essential expertise for analyzing cytokines and fecal calprotectin; Min J and Tran DQ conducted research on Treg analysis; Tu V and Wong C provided investigative pharmaceutical expertise during research; Ferris M, McMurty V and Zozoya M provided essential experience and expertise with high throughput sequence analysis of 16S rRNA gene sequences of fecal microbiota; Chunyan C, Rahbar MH and Hessabi M performed data management and statistical analyses; Fatheree NY, Liu Y, Ferris M and Rhoads JM wrote the paper; Rhoads JM has primary responsibility for content; all authors read and approved the final manuscript.
Supported by An Investigator Initiated Trial grant from Mead Johnson Nutrition which had no influence on the design or conduct of the study, data management and analysis, writing of the report, or the decision to submit the manuscript for publication.
Institutional review board statement: The study was reviewed and approved by the University of Texas Health Science Center at Houston Institutional Review Board.
Clinical trial registration statement: This registration policy applies to prospective, randomized, controlled trials only, NCT01279265.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: Not declared.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: J Marc Rhoads, MD, Department of Pediatrics, the University of Texas Health Science Center at Houston Medical School, 6431 Fannin St., MSB 3.137, Houston, TX 77030, United States.
Telephone: +1-713-5007642 Fax: +1-713-5005750
Received: March 27, 2015
Peer-review started: March 31, 2015
First decision: June 18, 2015
Revised: September 25, 2015
Accepted: November 3, 2015
Article in press: November 4, 2015
Published online: February 15, 2016

AIM: To investigate recruitment, retention, and estimates for effects of formula supplementation with Lactobacillus rhamnosus GG (LGG) on inflammatory biomarkers and fecal microbial community in infants with colic.

METHODS: A prospective, double-blind, placebo-controlled trial was conducted in otherwise healthy infants with colic. We screened 74 infants and randomized and analyzed results in 20 infants [9 receiving LGG (LGG+) and 11 not receiving LGG (LGG-)]. LGG was incorporated in the formula (Nutramigen®) (minimum of 3 × 107 CFU/d) in the LGG+ group. Fecal microbiota and inflammatory biomarkers, including fecal calprotectin (FC), plasma cytokines, circulating regulatory T cells (Tregs), and crying + fussing time were analyzed to determine optimal time points and effect sizes for a larger trial.

RESULTS: Recruitment in this population was slow, with about 66% of eligible infants willing to enroll; subject retention was better (75%). These rates were influenced by parents’ reluctance to volunteer their infant for a clinical trial and by their tendency to change formulas. The maximal difference of crying + fussing time was observed at day 14, comparing the 2 groups, with a mean difference of -91 (95%CI: -76, 259) min (P = NS). FC showed no significant difference, but the optimal time to determine a potential effect was at day 90 [with a mean difference of 121 (95%CI: -48, 291) μg/g stool], observing a lower level of FC in the LGG+ group. The fecal microbial communities were chaotic, as determined by Shannon’s diversity index and not apparently influenced by the probiotic. No significant change was observed in plasma inflammatory cytokines or Tregs, comparing LGG+ to LGG- groups.

CONCLUSION: Designing future colic trials involving a probiotic-supplemented formula for infants in the United States will require consideration for difficult enrollment. Infants with colic have major variations in feal microbiota and calprotectin, both of which improve with time, with optimal time points for measurement at days 14 and 90 after treatment.

Keywords: Barr diary, Regulatory T cells, Cytokines, Crying, Fussing, Probiotic, Inflammation, Biomarker, Newborn, Intestine

Core tip: The “dysbiosis” theory proposes that newborns with abnormal colonization are predisposed to having gut inflammation and colic. Probiotics may reduce crying and diversify the fecal microbiota. A prospective, double-blind, placebo-controlled trial was conducted in healthy infants with colic. After 75% screen failure or dropouts, 20 infants were analyzed (9 receiving formula with Lactobacillus GG and 11 not receiving Lactobacillus rhamnosus GG in their formula). We found that: (1) recruitment/retention indicate future randomized controlled trials should enroll 80 patients with an optimal timepoint for observing a potential difference in crying at 14 d; (2) microbial communities were chaotic in infants with colic, even more so than reported in Dutch infants; and (3) our study was the first to analyze cytokine levels and circulating Tregs in infants with colic.