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Research Article
Clinical trial

Effect of lactoferrin in oral nutrition supplement (ONS) towards IL-6 and IL-10 in failure to thrive children with infection

[version 1; peer review: 2 approved with reservations]
PUBLISHED 28 Jul 2023
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This article is included in the Agriculture, Food and Nutrition gateway.

This article is included in the Global Public Health gateway.

This article is included in the All trials matter collection.

Abstract

Background: Growth failure due to infection in children is a major health problem throughout the world. It provokes a systemic immune response, with increased interleukin (IL)-6 and reduced IL-10. Lactoferrin (Lf) is a multifunctional iron-binding protein that can be found in whey protein inside formula milk such as oral nutrition supplement (ONS), which can upregulate anti-inflammatory cytokines (IL-10) and modulate pro-inflammatory cytokines. This study investigates the effect of Lf supplementation in ONS on IL-6 and IL-10 levels in children with failure to thrive and infection.
Methods: We performed a quasi-experimental pre- and post-study in children aged 12–60 months old with failure to thrive due to infectious illness. The subjects received 400 ml of oral nutritional supplements (ONS, 1 ml equivalent to 1 kcal) each day for 90 days, and their parents received dietary advice and medication based on the underlying illness. Blood was drawn to measure IL-6 and IL-10 before and after the intervention.
Results: There were 75 subjects recruited and divided into group-1 and group-2 based on age. The incidence of undernutrition was 37.33%. Lf in ONS intervention improved body weight and body length. Lf also reduced IL-6, although there was not a significant difference before and after the intervention. However, the IL-6 reduction was significantly higher in subjects with undernutrition compared with subjects with weight faltering. Pre-intervention IL-6 levels were higher in children with stunting than in children with normal stature. There was a greater change in IL-6 in children with severe stunting than in children with normal stature or stunting. IL-10 was significantly reduced after the intervention.
Conclusions: In addition to improving body weight and length, Lf supplementation in ONS improved immune response homeostasis by balancing IL-6 and IL-10 levels and by improving the IL-6/IL-10 ratio.
ClinicalTrials.gov number ID: NCT05289674, dated May 3rd 2022.

Keywords

IL-6, IL-10, lactoferrin, growth failure

Introduction

Growth failure is still an important health problem, with weight-for-age (WAZ) and length-for-age (LAZ) declining during the golden period or golden 1,000 days (period during pregnancy until second years of life),1 and insignificant growth thereafter.2 Nutritional intervention during this period will impact a child’s growth, development and ability to thrive.1 Infection in children causes growth failure by provoking a systemic immune response which affects the nutritional status,3 especially as a result of a reduction of insulin-like growth factor 1 (IGF-1).4

Undernutrition refers to children who are underweight, stunted or wasted, or have nutrient deficiency which makes the children vulnerable to infection.5 The induction of the acute phase response and proinflammatory cytokine production caused by infection directly affect bone remodeling which is important for long bone growth,3 and also inhibits chondrogenesis.6 Pro-inflammatory cytokines such as interleukin (IL)-1β, IL-6 and tumor necrosis factor-alpha (TNF-α) were found to have increased in stunted children, which also increases leptin levels leading to a limited appetite.4 These proinflammatory cytokines also cause bone breakdown.6 IL-6 has anti- and pro-inflammatory functions. After it binds with IL-6 receptors in the liver, it stimulates hepatocytes to produce acute-phase proteins and cytokines via multiple signaling pathways.7

Oral nutritional supplements (ONS), also known as food for special medical purposes, contain both macro- and micronutrients that are sufficient to meet daily nutritional needs for those at risk of malnutrition.8 ONS is prescribed to increase nutritional intake due to insufficiency in diets to meet daily nutritional requirements,9 particularly protein and calories.10 ONS not only provides some benefits for hospital admission patients such as a reduced length of hospital stay (LOS), reduced inpatient cost, complication rates, readmission rates and improved lean body mass recovery,11 but also improves energy intake and nutritional status such as body weight, length and mid-arm circumference.12 For children, ONS is a dairy milk-based product, which is designed to provide an energy density of 1–1.5 kcal/ml, and it is expected to be effective in improving growth.13

Lactoferrin (Lf) concentration within the whey protein that is contained in the modified cow’s milk formula is only 0.1 mg/ml.14 ONS contains 10.8 g of protein per 100 g, which is 46% whey and 54% casein. The effect of Lf supplementation (dose 0.6 g/L and 1.00) compared to standard infant formula on body weight showed no significant difference in children until 12 months old.15 Lf acts as an innate immune regulator and defense due to its antimicrobial properties.16 It can interact with the immune system, such as influencing cytokine activity by upregulating anti-inflammatory cytokines (IL-4 and IL-10) or modulating proinflammatory cytokines.17 An in vitro study showed that Lf (10 mg/mouse i.v.) before thymectomy reduced IL-6 by 70%, and TNF-α by 30% 4 hours after an operation.18 A study in adults showed that Lf reduced systemic inflammatory biomarkers by 61%, improved immune function by 75%, changed immune cell activity by 40% and reduced respiratory tract infection outcomes by 60%. In adults, lactoferrin has been shown to reduce IL-6 by 24.9 pg/mL.19

Here we investigate the effect of lactoferrin in ONS towards IL-6 and IL-10 in failure to thrive children with infection for 90 days of intervention.

Methods

Ethical statement

The study passed ethical exemption and was declared to be ethically appropriate by the Health Research Ethics Committee, Airlangga University, Surabaya, Indonesia, number 226/EC/KEPK/FKUA/2021 on October 4th 2021 and registered on ClinicalTrials.gov number ID: NCT05289674, initial released on May 3rd, 2022.

Participants

A quasi experimental pre- and post- study design was performed from October 2021 until July 2022 recruiting children aged between 1 years (12-months-old) and 5 years (60-months-old) with failure to thrive due to infectious illness (mainly urinary tract infection and tuberculosis (TB)) diagnosed by a paediatrician (the researcher) based on clinical and laboratory findings at Husada Utama Hospital outpatient unit, Surabaya, Indonesia. The subjects included in the study were excluded if they had fluid retention, organomegaly, a tumor mass, congenital abnormalities, cerebral palsy or hormonal disorders and syndromes. A written informed consent was signed by the parents as approval to participate in the study after the researcher explained the importance, the risks and the benefits of this study.

Sample size

The sample size was determined using the formula below:

n1=n2=2PQ+P1Q1+P2Q22P1P22

Note:

N = sample size

= standard deviation (α) 5% (1.96)

= power, the researchers determined 90% (0.842)

P1 = clinical judgement 15% = 0.1

P2 = standard effect P2 = 25.5% = 0.25.20

P = ½ (P1+P2) = 0.175

Q = 1-P = 0.825

Q1 = 1-P1 = 0.9

Q2 = 1-P2 = 0.75

The sample size was 80 subjects; pre- and post-design needed for the study was 160 samples.

Interventions

The subjects were given an oral nutritional supplement or ONS with Lf (1 ml ~1 kcal, 400 ml/day), SGM Eksplor Gain Optigrow® prescribed by the researchers for 15 days consumption (equal to 4 boxes of 400 g) for initial intervention to detect any adverse reaction. The authors used this formula due to its relatively cheaper cost compared to other high calorie formula (ONS) available in Indonesia. The parents also had dietary counseling, animal protein was provided and a medication plan was given according to the underlying disease. Parents were asked to report any side effects to the researcher’s team by phone for further medical treatment. The parents were asked to visit the doctor after 14 days of ONS consumption for anthropometric measurements, compliance and side effect monitoring at day 15. While visiting, parents also received ONS for the next 15 days consumption (day 16 to 30), and were asked to visit the doctor again on day30, 60 and 90. At the 30-day visit, parents received ONS for two months’ consumption (day 31 to day 60, and day 61 until day 90) (8 boxes of 400 g) and anthropometric measurements.

Blood was withdrawn via vena cubiti by a laboratory employee at Husada Utama Hospital to measure IL-6 (human IL-6 ELISA kit, code E0090Hu, BT Lab) and IL-10 (human IL-10 ELISA kit, code E0102Hu, BT Lab) before (day 0, when the parents agreed to participate in this study) and after the intervention (day 90). After the blood samples were collected, they were placed in a non-EDTA containing tube for micro-centrifugation to separate blood plasma from blood serum at 3000 rpm for 10 minutes. The supernatant was removed and placed in a PCR tube of 1.5 mL, then kept in a freezer at -4oC.

An indirect sandwich ELISA was performed to analyse IL-6 and IL-10 levels before- and after nutritional intervention using blood serum. For the sandwich ELISA, all reagents (standard solution, wash buffer, substrate solution A, substrate solution B and stop solution) were brought to room temperature before use (27oC).21

Preparation of standard solution

A total of 120 μL standard solution (640 ng/ml) was diluted with 12 μL standard diluent to produce a 320 ng/L standard stock solution, and it was then allowed to rest for 15 minutes. Standard duplication points were made using a serial dilution of standard stock solution to produce 160 ng/L, 80 ng/L, 40 ng/L and 20 ng/L solutions.

Preparation for wash buffer solution

Then 20 ml of wash buffer concentrate 25 × was added to distilled water to yield 500 mL of 1 × wash buffer. The wash buffer was mixed gently if crystals formed in the concentrate until the crystals had completely dissolved.

Assay procedure

The assay procedure was performed at room temperature after we determined the number of strips required for the assay, and then we inserted the strips in the frames for use.

  • 1. 50 μL of the standard solution was added into all the sample wells.

  • 2. Then 50 μL standard solution was added into the standard wells.

  • 3. 40 μL of sample was added to the sample wells and then 10 μL of human IL-6 or IL-10 antibody was added. Then 50 μl streptavidin-HRP was added to sample wells and standard wells, but not the blank control well. Each of them were mixed before the wells were placed on the plate and then sealed for incubation at 37oC for 60 minutes.

  • 4. After 60 minutes of incubation, the seals were removed, and the plates were washed 5 times with wash buffer; the wells were soaked in 300 μl of wash buffer for 30 seconds to 1 minute for each wash.

  • 5. 50 μl of substrate solution A and 50 μl of substrate solution B were added to each well and the plate was covered and incubated for 10 minutes at 37oC in the dark.

  • 6. 50 μl of stop solution was added to each well, so that the blue colour changed to yellow immediately.

We then determined the optical density (OD value) of each well immediately using a microplate reader set at 450 nm of wavelength within 30 minutes after the stop solution was added, and then the standard curve was made.21

Body weight was measured using a Seca 354 digital baby scale or a Seca 813 electronic flat scale) and body length/height was measured using a Seca 415 infantometer or Seca 213 stadiometer). Both measurements were taken twice by a trained nurse in the outpatient department of Husada Utama Hospital. The weight and length/height were the average value of the two measurements. When the subjects were weighed and measured, they wore light clothes without footwear or hair accessories. Anthropometry measurement for weight-for-age z-score (WAZ), length-for-age or height-for-age z-score or height-for-age z-score (LAZ/HAZ) and weight-for-length or weight-for-height z-score or weight-for-height z-score (WLZ/WHZ) were determined using WHO Anthro offline version 3.2.2. All the data are summarized in the underlying data22 and extended data.23

Statistical analysis

Statistical analysis conducted in this study was a test of normality and homogeneity, independent sample T-test or Mann-Whitney U test, Fischer exact test, Pearson chi-square, paired sample T-test or Wilcoxon, two-way ANOVA and one-way ANOVA using IBM SPSS Statistics version 21.

Results

Seventy-five subjects were involved in the study and divided into two groups based on the age of the participant: group-1 (age 1–2 years, n = 39) and group-2 (age 2–5 years old, n = 36), as summarized in Figure 1.

ff6680e3-6507-4332-9c80-c11fc9224dab_figure1.gif

Figure 1. Flowchart of the subject’s recruitment.

Table 1 summarizes the characteristics of the subjects who participated in the study. The ratio of male/female was 12/13 and there was no significant difference in gender distribution in both groups (p = 0.108). There was no significant difference in the main complaint (p = 0.229), duration of complaints (p = 0.580), WAZ (p = 0.482) and WLZ/WHZ (p = 0.499). Age, ideal body weight and height age were lower in group-1 compared to group-2 (p < 0.05). LAZ was lower in group-1 compared to group-2 (-1.95 ± 1.17 vs. -1.19 ± 0.86, p = 0.002).

Table 1. Subject’s characteristic during the study.

Subject’s characteristicsGroup-1 (mean ± SD)Group-2 (mean ± SD)p
Age, months16.74 ± 3.6335.44 ± 7.700.0001
Gender, n (%)0.1082
- Male15 (36.59)21 (58.33)
- Female24 (58.53)15 (41.67)
Main complains:0.2293
- Feeding difficulties with stagnant body weight gain10 (25.64)16 (44.44)
- Stagnant body weight gain and length gain1 (2.56)0
- Body weight gain27 (69.29)20 (55.56)
- Fever with liquid pups1 (2.56)0
Duration of complaint, months7.84 ± 4.2912.23 ± 11.150.5801
WAZ-1.52 ± 1.08-1.35 ± 0.990.4824
WAZ categories, n (%)0.8743
- Weight faltering (normo-weight)25 (64.10)21 (58.33)
- Underweight12 (30.77)13 (36.11)
- Severely underweight2 (5.13)2 (5.56)
LAZ/HAZ-1.95 ± 1.17-1.19 ± 0.860.0024
LAZ/HAZ categories, n (%)0.0043
- Normo-stature17 (43.59)29 (80.56)
- Stunted14 (35.90)5 (13.89)
8 (20.51)2 (5.56)
- Severely stunted
WLZ/WHZ-0.85 ± 0.92-1.01 ± 1.120.4994
WLZ/WHZ categories, n (%)0.4863
- Good nutrition35 (89.74)29 (80.56)
- Wasted3 (7.69)6 (16.67)
- Severely wasted1 (2.56)1 (2.78)

1 Mann-Whitney U Test.

2 Fischer’s Exact Test.

3 Pearson Chi Square.

4 Independent Sample T-Test.

The incidence of underweight and severely underweight children in group-1 and group-2 were 33.33% and 5.33% respectively, and there was no significant difference in WAZ categories in both groups (p = 0.874). While stunted and severely stunted children in group-1 and group-2 were 25.33% and 13.33% respectively, with a higher incidence of stunted/severely stunted children in group-1 compared to group-2 (56.41% vs. 19.45%, p = 0.004). However, the incidence of stunted/severely stunted children in group-1 was predominantly boys (6 boys vs. 1 girl). The incidence of wasted and severely wasted children in group-1 and group-2 were 12% and 2.67% (p = 0.486).

The effect of ONS on body weight and body length/height change is summarized in Table 2. Initial body weight before treatment was lower in group-1 compared to group-2 (p = 0.000). post intervention body weight was lower in group-1 than in those of group-2 (p = 0.000) but the weight change (Δ body weight) in both groups showed no significant difference (922.56 ± 671.28 vs. 855.55 ± 577.16 g, p > 0.05). The initial body length/height was shorter in group-1 compared to group-2 (p = 0.000), so the late body length/height was shorter in group-1 compared to group-2 (p = 0.000). Body length/height change was greater in group-1 compared to group-2 (3.49 ± 1.43 vs. 2.08 ± 1.04 cm, p = 0.000).

Table 2. Body weight (in g) and body length/height (in cm) changes after intervention.

ParametersGroup-1 (mean ± SD)Group-2 (mean ± SD)p
Initial body weight8,735.38 ± 1,318.6412,164.17 ± 1,688.890.0001
Late body weight9,657.95 ± 1,607.4813,019.72 ± 1,768.910.0001
Body weight change (Δ Body weight)922.56 ± 671.28855.55 ± 577.160.6461
Initial body length/height75.14 ± 5.2691.39 ± 4.800.0001
Late body length/height78.63 ± 5.0293.47 ± 4.840.0001
Body length/height change (Δ length/height)3.49 ± 1.432.08 ± 1.040.0001

1 Independent sample T-test.

IL-6 and IL-10 levels during the intervention are summarized in Table 3. The levels of IL-6 post-intervention (day 90) were not significantly different from pre-intervention (128.45 ± 109.92 vs. 111.76 ± 78.10 pg/mL, p = 0.554), although there was a decline (-16.68 ± 91.09 pg/mL) in both groups (-13.42 ± 97.80 vs. -20.23 ± 84.46 pg/mL, p = 0.749). There was no significant difference in IL-6 levels before the treatment in both groups (p < 0.232) and after treatment (p < 0.191). IL-10 level was significantly reduced after the intervention (461.20 ± 392.12 became 261.28 ± 163.97 pg/mL, Δ = 199.92 ± 339.01 pg/mL, p = 0.000). The reduction in IL-10 showed no significant difference in either group (-183.24 ± 378.50 vs. -217.99 ± 294.61 pg/mL, p = 0.518).

Table 3. IL-6 and IL-10 in both group-1 and group-2 (in pg/mL).

IL-6 markersGroup-1 (mean ± SD)Group-2 (mean ± SD)p
Initial levels of IL-6113.80 ± 109.24144.31 ± 109.960.2321
Initial levels of IL-6 based on nutritional status0.6692
- Weight faltering94.12 ± 85.49126.13 ± 93.17
- Undernutrition136.76 ± 130.54191.58 ± 139.54
Late levels of IL-6100.38 ± 73.95124.09 ± 81.590.1911
Late levels of IL-6 based on nutritional status0.1212
- Weight faltering95.31 ± 70.06115.52 ± 76.85
- Undernutrition108.51 ± 81.65166.89 ± 98.51
Δ IL-6-13.42 ± 97.80-20.23 ± 84.460.7491
Δ IL-6 levels based on nutritional status0.0012
- Weight faltering-9.00 ± 83.72-19.86 ± 64.76
- Undernutrition-18.56 ± 114.38-21.18 ± 126.85
Initial levels of IL-10423.66 ± 385.66501.88 ± 400.430.3921
Initial levels of IL-10 based on nutritional status0.1312
- Weight faltering407.09 ± 367.31411.74 ± 318.22
- Undernutrition442.99 ± 415.93736.23 ± 507.72
Late levels of IL-10240.41 ± 165.75283.89 ± 161.270.2541
Late levels of IL-10 based on nutritional status0.6502
- Weight faltering211.15 ± 100.40256.25 ± 137.08
- Undernutrition274.56 ± 217.39355.76 ± 202.48
Δ IL-10-183.24 ± 378.50-217.99 ± 294.610.6611
Δ IL-10 levels based on nutritional status0.1132
- Weight faltering-195.94 ± 345.44-155.49 ± 234.96
- Undernutrition)-168.43 ± 423.58-380.47 ± 378.91
Initial value of IL-6/IL-10 ratio0.33 ± 0.280.33 ± 0.140.9911
Initial value of IL-6/IL-10 ratio based on nutritional status0.1792
- Weight faltering0.28 ± 0.170.34 ± 0.16
- Undernutrition0.38 ± 0.370.29 ± 0.16
Late value of IL-6/IL-10 ratio0.43 ± 0.120.45 ± 0.120.6161
Late value of IL-6/IL-10 ratio based on nutritional status0.5602
- Weight faltering0.43 ± 0.120.44 ± 0.11
- Undernutrition0.44 ± 0.110.47 ± 0.12
Δ IL-6/IL-10 ratio0.12 ± 0.290.12 ± 0.170.2621
Δ IL-6/IL-10 ratio based on nutritional status0.1252
- Weight faltering0.15 ± 0.191.00 ± 0.16
- Undernutrition0.06 ± 0.370.18 ± 0.21

1 Independent sample T-test.

2 Two-way ANOVA.

There was significantly improvement in the IL-6/IL-10 ratio after the intervention (0.33 ± 0.22 vs. 0.44 ± 0.12, Δ = 0.11 ± 0.23, p = 0.000). The reduction in the IL-6/IL-10 ratio showed no significant difference in either group (0.11 ± 0.29 vs. 0.12 ± 0.17, p = 0.991).

The levels of IL-6 based on anthropometric categories are summarized in Table 4. Based on the LAZ categories, there was a significant difference in IL-6 levels pre-intervention (p = 0.045), in which the stunted group had higher levels of IL-6 compared to those with a normal stature (212.06 ± 146.05 vs. 115.81 ± 93.84 pg/mL, p = 0.037). Although there was no significant difference, IL-6 was higher in the stunted group compared to those who were severely stunted (212.06 ± 146.05 vs. 85.45 ± 89.06 cm, p = 0.057). There was no significant difference in post-intervention levels of IL-6 (p = 0.083); however, IL-6 was lower in normal stature children compared to stunted and severely stunted children. Although IL-6 levels were higher in the stunted group compared to the severely stunted group, there was no significant difference between both groups (212.06 ± 146.05 vs. 85.45 ± 89.06 pg/mL, p = 0.057). Changes in IL-6 (ΔIL-6) based on the LAZ/HAZ categories showed no significant difference (p = 0.055), but the changes in severely stunted children were higher compared to the stunted group (47.33 ± 93.48 vs. -41.66 ± 108.69 pg/mL, p = 0.036) and the normal stature group (47.33 ± 93.48 vs. -20.28 ± 77.36 pg/mL, p = 0.031). This was due to increased IL-6 in severely stunted children, but reduced IL-6 in stunted children and those of normal stature.

Table 4. IL-6 levels based on anthropometry categories.

MarkersPre-intervention (mean ± SD)Post-intervention (mean ± SD)ΔIL-6 (mean ± SD)
IL-6 based on LAZ/HAZ categories
- Normo-stature115.81 ± 93.84104.81 ± 48.67-20.28 ± 77.36
- Stunted212.06 ± 146.05117.51 ± 115.94-41.66 ± 108.69
- Severely stunted85.45 ± 89.06132.78 ± 103.0347.33 ± 93.48
p value0.04520.08310.0552
IL-6 based on WAZ categories
- Normo-weight125.59 ± 99.41109.49 ± 75.87-16.09 ± 73.95
- Underweight145.73 ± 151.51101.54 ± 73.55-44.19 ± 137.03
- severely underweight103.70 ± 85.38181.84 ± 111.8578.14 ± 32.06
p value0.90320.17310.0142
IL-6 based on WLZ/WHZ categories
- Good nutritional status131.54 ± 110.91109.49 ± 75.98-22.05 ± 92.83
- Wasted129.02 ± 110.60138.75 ± 97.469.73 ± 84.73
- Severely wasted26.83 ± 5.2663.04 ± 8.7236.22 ± 3.46
p value0.23520.39110.1482

1 One-way ANOVA.

2 Kruskal-Wallis.

The levels of IL-6 based on the WAZ categories showed no significant difference pre-intervention (p = 0.903) or post-intervention (p = 0.173), but the change in IL-6 (ΔIL-6) showed a significant difference (p = 0.014), where the WAZ in severely underweight children increased, while the underweight and weight faltering decreased. Therefore, severely underweight children had higher changes of IL-6 compared to stunted children (78.14 ± 32.06 vs. -44.19 ± 137.03 pg/mL, p = 0.012) and weight faltering/normal weight children (78.14 ± 32.06 vs. -16.09 ± 73.95 pg/mL, p = 0.001).

The initial and late changes of IL-6 (ΔIL-6) based on WLZ/WHZ categories showed no significant difference (p > 0.05). The initial level of IL-6 was higher in good nutritional status subjects compared to wasted and severely wasted. But after the intervention, IL-6 levels in good nutritional status subjects were reduced (-22.05 ± 92.83 pg/ml), while the wasted and severely wasted group increased (9.73 ± 84.73 and 36.22 ± 3.46 pg/ml respectively).

Initial and late levels of IL-10, and changes of IL-10 based on the anthropometric categories are summarized in Table 5. There was no significant difference in IL-10 before and after the intervention, or in changes of IL-10 (p < 0.05) based on the LAZ/HAZ categories. A similar phenomenon was also seen in the WAZ and WLZ/WHZ categories (p < 0.05).

Table 5. IL-10 levels based on anthropometry categories.

MarkersPre-interventionPost-interventionΔIL-10
IL-10 based on LAZ/HAZ categories
- Normo-stature (n = 52)420.51 ± 350.98242.98 ± 133.22-177.53 ± 292.88
- Stunted (n = 13)666.72 ± 451.21302.92 ± 213.36-363.80 ± 413.83
- Severely stunted (n = 10)405.61 ± 469.84302.30 ± 213.36-103.31 ± 422.42
p value0.11410.53510.0762
IL-10 based on WAZ categories
- Weight faltering (normo-weight (n = 56)437.99 ± 351.68253.73 ± 148.63-184.25 ± 297.31
- Underweight (n = 15)497.15 ± 477.20260.51 ± 216.90-236.64 ± 440.80
- severely underweight (n = 4)651.36 ± 630.80369.88 ± 147.97-281.48 ± 536.04
p value0.53810.39710.9562
IL-10 based on WLZ/WHZ categories
- Good nutritional status (n = 64)457.82 ± 370.84257.03 ± 159.36-200.79 ± 331.63
- Wasted (n = 9)571.20 ± 536.68320.00 ± 201.23-251.19 ± 421.01
- Severely wasted (n = 2)74.55 ± 40.29133.16 ± 25.8958.61 ± 14.41
p value0.26810.30210.1562

1 One-way ANOVA.

2 Kruskal-Wallis.

The IL-6/IL-10 ratio based on anthropometric measurements is summarized in Table 6. The IL-6/IL-10 ratio based on the LAZ/HAZ categories showed no significant difference pre- and post-intervention. However, ONS supplementation increased the IL-6/IL-10 ratio in all LAZ/HAZ categories. In the WAZ categories, severely underweight children had a lower IL-6/IL-10 ratio compared to underweight children, even though there was no significant difference. The IL-6/IL-10 ratio increased after ONS therapy in all WAZ categories. A higher increment was seen in the severely underweight, but there was no significant difference. The WLZ/WHZ categories also showed no significant difference in the initial and late changes of the IL-6/IL-10 ratio.

Table 6. IL-6/IL-10 ratio based on anthropometric

MarkersPre-interventionPost-interventionΔIL-10
IL-6/IL-10 based on LAZ/HAZ categories
- Normo-stature (n = 52)0.32 ± 0.160.43 ± 0.110.12 ± 0.02
- Stunted (n = 13)0.39 ± 0.380.45 ± 0.130.07 ± 0.41
- Severely stunted (n = 10)0.30 ± 0.270.46 ± 0.110.15 ± 0.27
p value0.39020.76410.6981
IL-6/IL-10 based on WAZ categories
- Weight faltering (normo-weight (n = 56)0.34 ± 0.240.44 ± 0.160.10 ± 0.26
- Underweight (n = 15)0.30 ± 0.160.43 ± 0.110.12 ± 0.13
- severely underweight (n = 4)0.19 ± 0.040.47 ± 0.160.28 ± 0.18
p value0.14120.80910.3401
IL-6/IL-10 based on WLZ/WHZ categories
- Good nutritional status (n = 64)0.33 ± 0.230.44 ± 0.110.11 ± 0.25
- Wasted (n = 9)0.28 ± 0.140.45 ± 0.120.17 ± 0.18
- Severely wasted (n = 2)0.44 ± 0.310.49 ± 0.160.05 ± 0.15
p value0.67520.80410.7391

1 One-way ANOVA.

2 Kruskal-Wallis.

Discussion

The prevalence of stunted and severely stunted children under two-years-old was 33.7%24 and 45.4% in Nigerian children,25 which was higher compared to this study. While the prevalence in two- to five-year-old children in Gaza was 19.6%,26 The prevalence of stunted/severely stunted children was higher in group-1 compared to group-2 in our study, which was similar to the study conducted in Nigeria, accounting for 45.5% vs. 12.2%.25 However, a study in West Sulawesi, Indonesia found that children aged two to five years had a higher incidence of stunted/severely stunted growth compared to children aged one- to two-years-old, 33.64 vs. 23.12%.27

Stunted growth was found to be associated with age, and it was more prevalent in children aged less than 24-months-old.28 Due to the incidence of stunted growth, which was higher in group-1, the LAZ value was significantly lower in group-1 compared to group-2. It was also found that children with stunted growth were significantly shorter in length/height than the control group in another study.29 It was reported that children aged 12–23 months old had an increased risk of stunting by 1.8 times.24,30

In group-2, the incidence of stunted/severely stunted growth was predominant in males, which is in line with Akombi et al. (2017), in which male (sex) was one of the stunting risk factors in 0–5-year-olds.25 This is in line with this study, suggesting that males are more vulnerable to health inequalities.31 The biological reason is due to the sex difference in the immune and endocrine systems, and testosterone, luteinizing hormone and follicle stimulating hormone are suspected to play a role.32 Feeding practice preferences between boys and girls such as early weaning in boys, and boys tend to consume greater than one meal of complementary feed during 24-hours may also play a part.33

ONS intervention in undernourished or at nutritional risk children aged nine months to 12-years-old improved body weight by 0.423 kg after six months of intervention and height gain was 0.417 cm compared to the control, with greater gains in weight in the first 7–10 days of intervention (0.089 kg).34 ONS improved growth in underweight children aged five- to 12-years-old after six and 12 months,35 which was in line with this study, where both group-1 and group-2 gained weight. Formula feeding supplemented with lactoferrin is safe for infants under one year old with no difference in growth rate (g/day).15

Lactoferrin intervention in children with diarrhoea aged 12–36 months old increased the LAZ/HAZ score (p = 0.03) compared to the placebo,36 and the children also showed an increment in length/height. A similar result was also found in Vietnamese children aged 24–48 months old in a 12-month intervention. The intervention of 450 kcal of additional ONS during the first three months resulted in an increase in height of 1.62 cm,37 which was lower than our results in a similar group (group-2). A higher calorie density intervention (2.4 kcal/ml vs. 1.5 kcal/ml) for 28 days increased the children’s height by 0.87 [0.59–1.16] and 0.55 [0.17–0.93] cm, p = 0.007 in children aged greater than one year and less than 12 years old with growth faltering.13

Lactoferrin is known to have a bacteriostatic or bactericidal effect and can activate the immune response of an organism, act accordingly and limits tissue damage.38 It can therefore reduce the incidence of acute gastrointestinal symptoms and reduce the duration of respiratory symptoms in children under 12 months old due to viral or bacterial infection.39 Regarding the immunological profile, when comparing an infant who received Lf supplementation vs. non-Lf supplementation vs. standard infant formula, although there was no significant difference between groups, there was an increase in TGF-β1 (6.5 vs. 4.3 vs. 2.8 ng/mL), TGF-β2 (0.26 vs. 0.26 vs. 0.22 ng/mL) and IL-2 (0.21 vs. 0.5 vs. 0.4 pg/mL), but a decrease in TNF-α (-2.4 vs. -1.5 vs. -1.7 pg/mL) during a four month intervention.40 A study that examined piglets with a 2 ml/day supplementation showed a decrease in bacterial colonies compared to those without Lf supplementation (1.109 × 107 vs. 3.6183 × 108 CFU) via an anal swab after a seven-day intervention.41 It was stated that Lf induced the development of T cell helper type 1 (Th1) immunity, so created the balance of monocytic pro- and anti-inflammatory cytokines. In a dose-dependent manner, Lf enhanced pro-inflammatory response in vitro (splenocyte and adherent (F4/80+) splenocyte populations, bone marrow derived monocytes (BMM), and J774A.1 cultured cells) and induced IL-12 and IL-10 production and increased the ratio IL-12:IL-10 in lipopolysaccharide (LPS) stimulated cells.42 A study of Mycobacterium tuberculosis infection treated with Bacillus Calmette–Guérin (BCG) and Lf emulsified with Freund’s adjuvant in mice showed a decreased mycobacterial load in the lungs and spleen. It also increased the protection against M. tuberculosis,16,43,44 via downregulation of proinflammatory mediators (TNF-α, IL-1β) by modulation of macrophages and dendritic cell ability to present antigens and stimulate T-cells. Lf also increased IFNγ, which was the specific response towards Th1.16 A study examining mice with urinary tract infection due to Escherichia coli showed that Lf intervention orally was able to decrease the number of bacteria in the kidneys and bladder after 24 h of Lf consumption, and reduced IL-6 by urinary leucocytes.45 A study conducted on Senegalese children receiving tetanus vaccine in stunted children aged one- to nine-years-old showed that the production of IFNγ was compromised.2 It was stated that undernutrition is related to immunodeficiency even when it is mild, whether the innate or adaptive immune systems.2

In our study, even though there was no significant difference in IL-6 levels before and after the intervention, Lf reduced IL-6, which is in line with other studies showing a reduction in undernutrition groups. It was found that IL-6 levels were lower in undernutrition compared to good nutrition groups (2.54 pg/mL vs. 6.02 pg/mL, p < 0.0001).46 Genetic investigation showed that the IL-6 164 gene with a GG and GC genotype (mutant phenotype) was more frequent in undernourished children.47

When the groups were examined based on the LAZ/HAZ categories, stunted subjects had higher IL-6 levels compared to normal stature and there was a significant difference compared to severely stunted. This is in line with a study in Egyptian children, where IL-6 was higher in stunted compared to normal stature children (1.6 ± 0.2 vs. 1.5 ± 0.3 pg/mL),48 but it was decreased in malnourished compared to normal children.46 This showed that when the children had an LAZ/HAZ score greater than or equal to -2 SD, IL-6 was increased but it decreased when children had an LAZ/HAZ score greater or equal to -3 SD. On malnutrition, the acute-phase response was attenuated, and the production of cytokines decreased. An animal study showed that IL-1β production decreased in malnourished guinea pigs induced with endotoxins.7 Stunting is a form of growth failure due to long term nutritional deficiency or it is caused by chronic malnutrition or recurrent undernutrition.49,50 After a six-month intervention with food supplementation, stunted Bangladeshi children aged 12–18 months old experienced an IL-6 increment (from 0 [0–1.2] to 1.68 [0.83–4.7] pg/mL, p = 0.001),51 which contradicts this study as IL-6 levels were reduced in stunted and normal stature children. However, IL-6 was found to have increased in severely stunted children, so the post-intervention levels of IL-6 were higher in severely stunted even though there was no significant difference. Severely stunted children might undergo these immune alterations which are similar to severely acute malnutrition, so IL-6 levels were lowest at the outset but increased drastically after the intervention to surpass normal stature and stunted children. It was stated that immune function is an activity with high costs on energy demand, and in developing children the allocation of energy in immune functions may lead to a trade-off with physical growth, particularly those with exposure to infection.52

A similar anomaly was also seen in the WAZ categories even though there was no significant difference. Being underweight has been used as an indicator of undernutrition due to a short-term nutritional deficiency.49 However, an in vitro study using peripheral blood mononuclear cells (PBMC) taken from children suffering from protein energy malnutrition (PEM) contradicted this study, which showed an increment in IL-6 expression after stimulation with LPS,53 even though it was expressed earlier, reached its peak earlier, and lasted longer than controls in rats.54 As the immune function is costly in terms of energy, it has negative effects on growth. In children with mildly elevated immune activity, they experience a growth reduction of up to 49%,52 as seen in underweight children who experienced an increase in IL-6 due to the trade-off in body fat between immune function and growth.52

Regarding malnutrition, lymphatic tissue, particularly the thymus, experiences atrophy, leads to a reduction in delayed-type hypersensitivity responses, followed by a reduction in levels of antibodies in severely malnourished children (≥-3 SD of WLZ/WHZ WHO child growth standards), but it remains intact in moderate malnutrition (leucocyte and lymphocyte, high levels of immunoglobulin, particularly IgA, and acute phase response), and cytokine patterns are skewed towards a Th2-response.55 However, our study found that IL-6 started to reduce in wasted patients, with the lowest levels in those that were severely wasted. Nutritional intervention increases IL-6 in both wasted and severely wasted, but it is reduced with good nutrition, which is in line with research that states undernutrition, even in the mildest form causes immunodeficiency.56

Wenling C57BL/6 J mice in a wasting model’s study, which underwent 14 days of weight loss, showed increases of IL-10 in the malnourished group at three and at 14 days.57 It was stated that malnutrition modifies the body’s resistance against infection, particularly the immune response. Lipopolysaccharide (LPS) injection (1.25 μg i.v.) in a protein-energy malnutrition (PEM) mouse model, showed that the circulating levels of IL-10 were increased, and high levels were found in bone marrow cells, which showed immunodeficiency.58 This finding was in-line with a study in children with marasmic-PEM, IL-10 was significantly higher compared to controls (19.08 ± 5.93 vs 10.46 ± 3.90 pg/mL; p = 0.000).59 This may be caused by the deficits of NF-kB activation. NF-kB was the major transcription pathway for proinflammatory cytokine production.60 Using BMI as the parameter to determine malnutrition, subjects with severe malnutrition (BMI <16.5) had higher levels of IL-10 (8.0 ± 3.6 pg/mL) compared to those with moderate malnutrition (BMI = 16.5-18.4) (2.6 ± 4.3 pg/mL) and good nutrition (BMI >18.5) (2.8 ± 0.7 pg/mL) in adults,61 which was similar to the WAZ category where IL-10 was slightly increased in those underweight, and increased drastically in those severely underweight.

Nutritional intervention increases IL-10 significantly in children aged 12–60 months old with moderate and severe malnutrition receiving curd (milk product) compared to leaf protein concentrate (LPC) (from 30.9 ± 29.5 to 67.4 ± 96.2 pg/mL vs. 29.2 ± 25.8 to 31.5 ± 24.9 pg/mL). Based on Gomez criteria for malnutrition severity, children with mild malnutrition had lower IL-10 compared to children with severe malnutrition. It was higher in subjects aged more than two years old compared to two- to five-year-olds due to a balancing pro-inflammatory response to minimalize tissue damage.62 In malnourished children, IL-10 was found to be reduced, while in line with this study, IL-10 was depressed in severely wasted subjects.63 However, the level of IL-10 was still normal in severely stunted or severely underweight children. The reduction is due to a deficiency in the number and functional Th cells, which may be caused by incomplete differentiation of T lymphocyte precursors and steroid-induced lympholysis.63 Another study of malnourished children due to inadequate food intake (anorexia nervosa) and diarrhoea receiving nutritional intervention in the form of milk and yogurt, showed increased IFNγ production post intervention,64 which is in-line with this study on severely wasted subjects. However, in undernutrition subjects and weight faltering subjects, IL-10 tends to reduce, and a higher reduction was seen in undernutrition subjects, which showed that before intervention undernutrition subjects may experience immune alterations, as seen in the IL-6/IL-10 ratio, which was higher in undernutrition group-1, but lower in group-2. At post intervention, almost all the group had a similar value, ranging from 0.43 to 0.47. Adipose tissue is the main storage for nutrients, which can sense that nutrients are inadequate by releasing adipokines (particularly leptin) to control cellular metabolism and immune function. So, undernutrition has a direct impact on adipose tissue (volume and number), and directly influences the immune system. Leptin not only mediates glucose and lipid metabolism but also immune function, by stimulating activation, proliferation and production of pro-inflammatory cytokine (IL-6, TNF-α, monocytes, macrophages, dendritic cells, and NK cells). Leptin also promotes T-cell activation and development towards Th-1 and Th-17 cell subset which is proinflammatory. Regarding undernutrition, there was leptin depletion and in contrast adiponectin is produced, resulting in the polarization towards M2 or an alternative macrophage which then secrets IL-10 and IL-1Rα. This limits the activation of the NF-kB pathway, and reduces both T-cells or B-cells. Moreover, cortisol hormone restrains the generation of the proinflammatory immune response, so the ability of macrophages and neutrophils to infiltrate the infection site was also restrained. Proinflammatory cytokine production is also reduced, but anti-inflammatory cytokines (IL-10 and IL-33) are increased.5

IL-6 has been used as a potential biomarker to identify patients receiving anti-inflammatory therapies as it is secreted widely as a response to pathological states such as infection, inflammation and cancer. IL-10 acts as an anti-inflammatory response, it is secreted as the response to dampen pro-inflammatory bursts and minimize tissue damage. The balance of IL-6 and IL-10 is an important biomarker reflecting the homeostasis of the immune response. In Covid-19 patients, each point increment of the IL-6/IL-10 ratio was associated with a 5.6 times more severe outcome.5 In children with pneumonia, the IL-6/IL-10 ratio at 9.61 determines those with severe pneumonia to those with mild disease (sensitivity 76.5% and specificity 93%).65

Conclusions

Lactoferrin in ONS intervention improved immune response homeostasis by balancing IL-6 and IL-10 and improved the IL-6/IL-10 ratio, not only body weight but also body length.

Consent

Written informed consent for publication of the patients’ details was obtained from the parents of the patients.

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Widjaja NA, Hamidah A, Purnomo MT and Ardianah E. Effect of lactoferrin in oral nutrition supplement (ONS) towards IL-6 and IL-10 in failure to thrive children with infection [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:897 (https://doi.org/10.12688/f1000research.130176.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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Reviewer Report 30 Aug 2023
Rachael Anyim, Anthropology, Binghamton University, Binghamton, New York, USA 
Mallory Peters, Anthropology, Binghamton University, Binghamton, New York, USA 
Approved with Reservations
VIEWS 52
Widjaja et al.’s manuscript highlights growth failure in children (diagnosed with infectious diseases) and whether lactoferrin in oral nutrition supplementation improves their immune responses, captured here via changes in pro-inflammatory and anti-inflammatory cytokines, interleukin-6 and interleukin-10, respectively. Participating children received ... Continue reading
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HOW TO CITE THIS REPORT
Anyim R and Peters M. Reviewer Report For: Effect of lactoferrin in oral nutrition supplement (ONS) towards IL-6 and IL-10 in failure to thrive children with infection [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:897 (https://doi.org/10.5256/f1000research.142910.r197396)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 20 Oct 2023
    Nur Aisiyah Widjaja, Airlangga University, Indonesia
    20 Oct 2023
    Author Response
    As a whole, the authors’ manuscript is very detailed and well written, evidenced by their thorough references to the current literature. The methods for data collection are written clearly for ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 20 Oct 2023
    Nur Aisiyah Widjaja, Airlangga University, Indonesia
    20 Oct 2023
    Author Response
    As a whole, the authors’ manuscript is very detailed and well written, evidenced by their thorough references to the current literature. The methods for data collection are written clearly for ... Continue reading
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28
Cite
Reviewer Report 29 Aug 2023
Vinutha U. Muktamath, University of Agricultural Sciences, Dharwad, India 
Approved with Reservations
VIEWS 28
The study is novel and addresses the most important issue of poor nutritional status leading to infant mortality and morbidity in infants and toddlers. Appropriate statistical tool and methodology is adopted. However the title can be more specific as effect ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Muktamath VU. Reviewer Report For: Effect of lactoferrin in oral nutrition supplement (ONS) towards IL-6 and IL-10 in failure to thrive children with infection [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:897 (https://doi.org/10.5256/f1000research.142910.r197395)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 20 Oct 2023
    Nur Aisiyah Widjaja, Airlangga University, Indonesia
    20 Oct 2023
    Author Response
    The study is novel and addresses the most important issue of poor nutritional status leading to infant mortality and morbidity in infants and toddlers. Appropriate statistical tool and methodology is ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 20 Oct 2023
    Nur Aisiyah Widjaja, Airlangga University, Indonesia
    20 Oct 2023
    Author Response
    The study is novel and addresses the most important issue of poor nutritional status leading to infant mortality and morbidity in infants and toddlers. Appropriate statistical tool and methodology is ... Continue reading

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 28 Jul 2023
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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