Lactoferrin and lysozyme to reduce environmental enteric dysfunction and stunting in Malawian children: study protocol for a randomized controlled trial

William D Cheng, Karl J Wold, Nicole S Benzoni, Chrissie Thakwalakwa, Kenneth M Maleta, Mark J Manary, Indi Trehan, William D Cheng, Karl J Wold, Nicole S Benzoni, Chrissie Thakwalakwa, Kenneth M Maleta, Mark J Manary, Indi Trehan

Abstract

Background: Chronic childhood malnutrition, as manifested by stunted linear growth, remains a persistent barrier to optimal child growth and societal development. Environmental enteric dysfunction (EED) is a significant underlying factor in the causal pathway to stunting, delayed cognitive development, and ultimately morbidity and mortality. Effective therapies against EED and stunting are lacking and further clinical trials are warranted to effectively identify and operationalize interventions.

Methods/design: A prospective randomized placebo-controlled parallel-group randomized controlled trial will be conducted to determine if a daily supplement of lactoferrin and lysozyme, two important proteins found in breast milk, can decrease the burden of EED and stunting in rural Malawian children aged 12-23 months old. The intervention and control groups will have a sample size of 86 subjects each. All field and laboratory researchers will be blinded to the assigned intervention group, as will the subjects and their caregivers. The percentage of ingested lactulose excreted in the urine (Δ%L) after 4 h will be used as the biomarker for EED and linear growth as the measure of chronic malnutrition (stunting). The primary outcomes of interest will be change in Δ%L from baseline to 8 weeks and to 16 weeks. Intention-to-treat analyses will be used.

Discussion: A rigorous clinical trial design will be used to assess the biologically plausible use of lactoferrin and lysozyme as dietary supplements for children at high risk for EED. If proven effective, these safe proteins may serve to markedly reduce the burden of childhood malnutrition and improve survival.

Trial registration: Clinicaltrials.gov, NCT02925026 . Registered on 4 October 2016.

Keywords: Environmental enteric dysfunction; Environmental enteropathy; Inflammation; Lactoferrin; Lactulose; Lysozyme; Malnutrition; Stunting.

Conflict of interest statement

Ethics approval and consent to participate

This study has been approved by the University of Malawi College of Medicine Ethics and Research Committee and the Washington University in St. Louis. Verbal and written consent is approved for all patients participating in the research.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Anticipated patient flow for the randomized clinical trial. *Defined as having weight-for-height Z score (WHZ) < –2, mid-upper arm circumference (MUAC) < 12.5 cm, and/or bilateral pitting edema suggestive of kwashiorkor
Fig. 2
Fig. 2
SPIRIT figure: study participation schedule for subjects

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