Early Life Malnutrition, Environmental Enteric Dysfunction and Microbiome Trajectories

NCT07195006 | Recruiting

• 2 other identifiers: MRCZ/A/3256JREC/451/2024
• Study Type: observational
• Target: 368
• Locations: 1 country
• Sites: 1

Brief Summary

Malnutrition in women of reproductive age remains a public health concern in Sub-Saharan Africa (SSA). Malnutrition during pregnancy affects foetal growth with a tendency of the exposed infants to also develop it. The interaction of the mother with the infant shapes the seeding and the trajectory of the infant intestinal microbiota which is crucial for development of a healthy immune system Malnutrition has been associated with intestinal inflammation, intestinal leakage and reduced calorie absorption. Early life malnutrition and environmental enteric dysfunction (EED) immunopathology remains poorly described in the context of mother-infant dyads. This is essential as malnutrition, poor water, sanitation and hygiene (WASH), including the presence of infectious diseases limit the developmental potential of the exposed infants in SSA, including Zimbabwe. In addition, maternal stress and poor mental health may also affect standard hygiene practices, including how a mother cares for her baby, potentially aggravating EED and the risk of the infant being malnourished. Primary outcomes

• MUAC for age: Malnourished defined as those below -2 standard (SD) of the World Health Organisation (WHO) reference
• Weight-for-age: Underweight defined as those below -2SD WHO reference
• Weight-for-height: Wasted defined as those below -2SD WHO reference
• Height-for-age: Stunted defined as those below -2SD WHO reference
• Z-scores (as they are i.e. a continuous variable, taking age of infants into account)
• A composite variable, any of malnourished, underweight, wasted or stunted.

Conditions

Malnutrition Pregnancy; Malnutrition in Children; Malnutrition (Calorie); Environmental Enteric Dysfunction; Gut Dysbiosis; Gut Permeability, Gut Inflammation; Diarrhea Infectious; Maternal Stress; Child Mental Health; Natural Killer Cell Mediated Immunity; Mycotoxin Biomonitoring; Environmental Exposures; Cell-Mediated Immune Deficiency

Keywords

diarrhoeal episodes; short chain fatty acids receptor agonists; intestinal inflammation, leakage and calory extraction; toxins in drinking water and food; macro- and micronutrient composition of breast milk; human anti-Gal antibodies; mitochondria health and nutrient uptake; endothelial dysfunction and oxidative stress; hormonal mediated molecular signalling mechanisms; interaction of epigenetics & socioeconomic factors; microbiota, pathobionts and oral microbiota; metagenomics; undernutrition and intestinal infections; infant mortality, morbidity within 1st 1000 days of life; low mid upper arm circumference; sleep adequacy in maternal mental health; chronic inflammation

Outcome Measures

Primary Outcomes (44)

• Alpha diversity of maternal gut microbiota

  Alpha diversity of maternal stool microbiota will be assessed by shotgun metagenomic sequencing, and calculated using the Shannon index. This measure reflects within-sample diversity and evenness of microbial communities. Unit of Measure: Shannon index (unitless; typical range 1-6)

  Third trimester of pregnancy, week(s) 1, 6, 14, 24, 48, 96, 144 after delivery

• Beta diversity of maternal gut microbiota

  Beta diversity of maternal stool microbiota will be assessed by shotgun metagenomic sequencing and calculated using Bray-Curtis dissimilarity. This measure reflects between-sample differences in community composition. Unit of Measure: % variance explained

  Third trimester of pregnancy, week(s) 1, 6, 14, 24, 48, 96, 144 after delivery

• Alpha diversity of human breast milk microbiota

  Alpha diversity of maternal breast milk microbiota will be assessed by shotgun metagenomic sequencing, and calculated using the Shannon index. This measure reflects within-sample diversity and evenness of microbial communities. Unit of Measure: Shannon index (unitless; typical range 1-6)

  Week(s) 1, 6, 14, 24, 48, 96, 144 after delivery/ until weaning

• Beta diversity of human breast milk microbiota

  Beta diversity of breast milk microbiota will be assessed by shotgun metagenomic sequencing, and calculated using Bray-Curtis dissimilarity. This measure reflects between-sample differences in community composition. Unit of Measure: % variance explained.

  Week(s) 1, 6, 14, 24, 48, 96, 144 after delivery/ until weaning

• Protein content of breast milk

  Breast milk samples will be analyzed by photo-spectrometric protein assays, such as the BSA assay. Comparison of milk of mothers of infants with and without clinical signs of malnutrition (defined by WHO growth standards: WLZ or LAZ \< -2), 100 infants per group. Unit of Measure: g/100mL

  Maternal breast milk samples collected at week(s) 1, 6, 14, 24, 48 post birth.

• Fat content of breast milk

  Breast milk samples will be analyzed by creamatocrit test. Comparison of milk of mothers of infants with and without clinical signs of malnutrition (defined by WHO growth standards: WLZ or LAZ \< -2), 100 infants per group. Unit of Measure: mL/100mL

  Maternal breast milk samples collected at week(s) 1, 6, 14, 24, 48 post birth.

• Lactose content of breast milk

  Breast milk samples will be analyzed by high-performance liquid chromatography (HPLC) Comparison of milk of mothers of infants with and without clinical signs of malnutrition (defined by WHO growth standards: WLZ or LAZ \< -2), 100 infants per group. Unit of Measure: g/100mL

  Maternal breast milk samples collected at week(s) 1, 6, 14, 24, 48 post birth.

• Micronutrient content of breast milk

  Breast milk micronutrients (vitamins A, D, B12, folate; trace elements such as iron, zinc, selenium) assessment using ELISA, and colorimetric assays. Comparison of milk of mothers of infants with and without clinical signs of malnutrition (defined by WHO growth standards: WLZ or LAZ \< -2), 100 infants per group. Vit A: µg/L• Vit D: ng/mL• Folate: ng/mL• Vitamin B12: pg/mL• Iron, zinc, selenium;µg/L.

  Maternal breast milk samples collected at week(s) 1, 6, 14, 24, 48 post birth.

• Metabolic composition of breast milk Assessing whether compositional differences in maternal milk are associated with infant intestinal development potential

  Breast milk samples will be analyzed by untargeted mass spectrometry. Comparison of milk of mothers of infants with and without clinical signs of malnutrition (defined by WHO growth standards: WLZ or LAZ \< -2), 100 infants per group. Unit of Measure: relative counts of ionized metabolites (mass-to-charge ratio, m/z)

  Maternal breast milk samples collected at week(s) 1, 6, 14, 24, 48 post birth.

• Impact of breast milk on infant intestinal organoid barrier function

  Primary infant-derived 2D intestinal epithelial organoids will be generated from patient biopsies and treated with diluted breast milk samples to assess epithelial cell proliferation, barrier maturation, and differentiation. Transepithelial electrical resistance (TEER) will be measured as a read-out of intestinal barrier. Comparison of milk of mothers of infants with and without clinical signs of malnutrition (defined by WHO growth standards: WLZ or LAZ \< -2), 100 infants per group. Unit of Measure: TEER: ohms·cm²

  Maternal breast milk samples collected at week(s) 1, 6, 14, 24 post birth.

• Impact of breast milk on infant intestinal organoid morphology

  Primary infant-derived 3D intestinal epithelial organoids will be generated from patient biopsies and treated with diluted breast milk samples for several days. Microscopy will be used to determine the organoid morphology: organoid-to-spheroid ratio. Comparison of milk of mothers of infants with and without clinical signs of malnutrition (defined by WHO growth standards: WLZ or LAZ \< -2), 100 infants per group. Organoid morphology: villus-crypt architecture scores Unit of Measure: qualitative/semi-quantitative

  Maternal breast milk samples collected at week(s) 1, 6, 14, 24 post birth.

• Impact of breast milk on infant intestinal organoid size

  Primary infant-derived 3D intestinal epithelial organoids will be generated from patient biopsies and treated with diluted breast milk samples for several days. Microscopy will be used to determine the organoid size. Comparison of milk of mothers of infants with and without clinical signs of malnutrition (defined by WHO growth standards: WLZ or LAZ \< -2), 100 infants per group. Unit of Measure: µm

  Maternal breast milk samples collected at week(s) 1, 6, 14, 24 post birth.

• Impact of breast milk on infant intestinal organoid gene expression

  Primary infant-derived 2D intestinal epithelial organoids will be generated from patient biopsies and treated with diluted breast milk samples for 24 hours. RNA will be isolated and used for reverse transcription quantitative polymerase chain reaction (RT-qPCR). Comparison of milk of mothers of infants with and without clinical signs of malnutrition (defined by WHO growth standards: WLZ or LAZ \< -2), 100 infants per group. Expression of tight junction proteins (e.g., ZO-1, occludin): relative fluorescence intensity Unit of Measure: relative expression of gene of interest in relation to housekeeping gene (2\^(-delta CT)) Unit of Measure: TEER: ohms·cm²

  Maternal breast milk samples collected at week(s) 1, 6, 14, 24 post birth.

• Alpha diversity of infant gut microbiota

  Alpha diversity of infant stool microbiota will be assessed by shotgun metagenomic sequencing, and calculated using the Shannon index. This measure reflects within-sample diversity and evenness of microbial communities. Unit of Measure: Shannon index (unitless; typical range 1-6)

  Week(s) 1, 6, 14, 24, 48, 96, 144 of age

• Beta diversity of infant gut microbiota

  Beta diversity of infant stool microbiota will be assessed by shotgun metagenomic sequencing and calculated using Bray-Curtis dissimilarity. This measure reflects between-sample differences in community composition. Unit of Measure: % variance explained.

  Week(s) 1, 6, 14, 24, 48, 96, 144 of age

• Relative abundance of dominant bacterial taxa and microbial metabolic pathways

  Relative abundance of dominant bacterial taxa in maternal and infant stool, including breast milk, and of microbial metabolic pathways (KEGG modules) in infant stool, will be determined using MetaPhlAn3 and HUMAnN3. Unit of Measure: % of total sequences assigned. Relative abundance (%) of dominant bacterial taxa in maternal and infant stool Relative abundance (%) of microbial metabolic pathways (KEGG) in infant stool.

  Maternal stool: third trimester, birth, 6, 12, and 24 months postpartum • Breast milk: birth, 6, and 12 months postpartum • Infant stool: birth, 6, 12, and 24 months old.

• Maternal serum immunoglobulin concentrations

  Total IgG, IgA, and IgM will be quantified in maternal serum using ELISA/Luminex assays as biomarkers of systemic and mucosal barrier function. Unit of Measure: mg/mL

  From pregnancy and once every year for 3 years

• Maternal levels of serum proteins

  Albumin, prealbumin, and total protein will be measured in maternal serum using ELISA/Luminex assays to assess intestinal barrier integrity and nutritional status. Unit of Measure: g/dL

  From pregnancy and once every year for 3 years

• Maternal levels of serum inflammatory markers

  Myeloperoxidase, neopterin, soluble CD14, soluble CD163 and C-reactive protein will be quantified using ELISA/Luminex assays in maternal serum as biomarkers of intestinal and systemic inflammation. Unit of measurement: µg or ng/mL

  Once in pregnancy, and once every year for 3 years.

• Maternal biomarkers of epithelial and microbial translocation

  Intestinal fatty-acid binding protein (I-FABP) and endotoxin core antibodies (EndoCAb) will be measured using ELISA/Luminex assays in maternal serum as biomarkers of epithelial barrier disruption and microbial translocation. Unit of Measure: pg/mL (I-FABP) and EU/mL (EndoCAb).

  Once in pregnancy, and once every year for 3 years.

• Maternal Iron and anabolism-related biomarkers

  Soluble transferrin receptor (sTfR), hepcidin, and insulin-like growth factor 1 (IGF-1) will be measured in maternal serum as biomarkers of iron status and systemic growth regulation. Unit of Measure: ng/mL

  Mother from pregnancy and once every year for 3 years

• Maternal serum biochemical indicators

  Urea, creatinine, and liver enzyme alkaline phosphatase will be measured in maternal serum to assess renal and hepatic function. Unit of Measure: mg/dL (urea, creatinine) and U/L (alkaline phosphatase)

  Once in pregnancy, and once every year for 3 years after delivery.

• Timing of infant malnutrition and oral health status

  The objective is to assess the relationship between the timing of malnutrition in the infant and the development of oral health issues: * Dental caries * Oral infections and other oral manifestations, * Enamel dysplasia) in children from 6 months to 2 years of age. The standardized oral health assessment tool will be used to describe the following; * Dmft index (decayed, missing, filled teeth) for dental caries * Visual examination for enamel dysplasia * Oral infections including other oral manifestations Oral thrush (fungal) Herpetic gingivostomatitis (herpes simplex virus) Tooth abscess (bacterial) Gangrenous disease noma (bacterial) Apthous stomatitis Eruption cysts around teething teeth

  From 6 months after delivery or birth and once a year for 2 years

• Correlation between Oral Health of mother and that of the child

  The objective is to evaluate the correlation between the oral health status of mothers and their children, including the presence of dental caries, oral infections, and periodontal disease. Measurement Tool: Standardized oral health assessment tools will be used to define the following * DMFT index (Decayed, Missing, Filled Teeth) for mothers * dmft index for children * Plaque Index (PI) and Gingival Index (GI) for both mothers and children Oral health issues: * Dental caries * Oral infections and other oral manifestations, * Enamel dysplasia) in children from 6 months to 2 years of age. * Plaque/Gingival index score; Total number of surfaces with plaque/gingivitisis divided by total number of observed surfaces.

  From 6 months after delivery or birth and once a year for 2 years

• Maternal socio-demographic and the development of infant malnutrition and gut dysfunction and mortality

  Determine the correlation between maternal socio-demographic, including household characteristics in pregnancy at least 20 weeks gestational age assessed using a questionnaire administered by a research nurse and, 1. adverse pregnancy outcomes (low birth weight, pre-maturity birth \< 37 weeks gestational age at birth 2. development of infant malnutrition from birth, weeks 6, 24, 24 48, 96 and 144 of age 3. Gut dysbiosis as in objective 1 above Comparing infants born of women in the 4 groups, malnourished versus normo-nourished in pregnancy at least 20 weeks gestational age by poor versus relatively better WASH living conditions Definition of malnutrition outcomes to be assessed * MUAC for age: Malnourished defined as those below -2SD WHO reference * Weight-for-age: Underweight defined as those below -2SD WHO reference * Weight-for-height: Wasted defined as those below -2SD WHO reference * Height-for-age: Stunted defined as those below -2SD WHO reference

  Mothers; from pregnancy and every 6 months until 3 years after deliveryInfants; from birth and every 6 months until 3 years old

• Maternal stress assessment using Cohen Perceived Stress Scale (CPSS)

  The CPSS tool measures the perception of stress in individuals and how unpredictable, uncontrollable, and overloaded mothers find their lives. It consists of 10 items with mothers rating their feelings and thoughts during the last month. Each item is scored 0 to 4: 0: Never 1. Almost never 2. Sometimes 3. Fairly often 4. Very often Total Score The total score is calculated by summing the scores of all items, yielding a range from 0 to 40: Low Stress: Scores between 0-13. Indicates low levels of perceived stress. Moderate Stress: Scores between 14-26. Suggests moderate levels of perceived stress. High Stress: Scores between 27-40. Indicates high levels of perceived stress. All the 300 mothers will be assessed.

  In pregnancy , weeks 6 and 24 months after delivery

• Maternal stress measurement using Edinburgh Post Partum Depression Scale (EPDS)

  EPDS screening tool will be used to identify mothers who may be experiencing postpartum depression. It consists of 10 multiple-choice questions, each focusing on the presence or absence symptoms experienced in the past week. Scoring Each item on the EPDS is scored from 0 to 3, with higher scores indicating more severe symptoms. The total score can range from 0 to 30. Categorization of Scores 0-9: Low risk of postpartum depression. Indicates minimal or no depressive symptoms. 10-12: Moderate risk of postpartum depression. Suggests the need for further evaluation and possibly monitoring. 13-30: High risk of postpartum depression. Indicates significant depressive symptoms and suggests the need for further assessment and intervention. All the 300 mothers will be assessed.

  weeks 6 and 24 weeks and 48 weeks after delivery

• Maternal sleeping disorders as indicator of stress using Pittsburgh Sleep Quality Index (PSQI)

  The PSQI has 7 components: * Subjective Sleep Quality: Self-rated sleep quality. * Sleep latency: Time taken to fall asleep. * Sleep Duration: Total hours of sleep per night. * Habitual Sleep Efficiency: Ratio of actual sleep time to time spent in bed. * Frequency of problems that disrupt sleep. * Use of sleeping medications to aid sleep. * Daytime Dysfunction: Impact of sleepiness or fatigue on daily activities. Scoring Each component is scored from 0 to 3, with higher scores indicating worse sleep quality. Total score ranges from 0 to 21. Interpretation 0-5: Good sleep quality 6-10: Moderate sleep problems 11-21: Severe sleep problems This assessment helps in identifying mothers who may require further evaluation or intervention for sleep-related issues. All the 300 mothers will be assessed.

  In pregnancy, weeks 6 and 24 months after delivery

• Sleeping disorders assessment using Epworth Sleepiness Scale (ESS)

  Maternal sleeping disorders will be screened using The ESS tool that measures daytime sleepiness and assesses mothers' propensity to fall asleep in different situations. It consists of eight scenarios where Mothers rate their likelihood of dozing off on a scale from 0 to 3. Each of the eight items is scored as follows: 0: Would never doze 1. Slight chance of dozing 2. Moderate chance of dozing 3. High chance of dozing All the eight scenarios are summed to give a total score ranging from 0 to 24. Interpretation 0-10: Normal daytime sleepiness 11-12: Mild excessive daytime sleepiness 13-15: Moderate excessive daytime sleepiness 16-24: Severe excessive daytime sleepiness This tool helps identifying mothers who may have sleep disorders or excessive daytime sleepiness that could impact their daily functioning, including caring for their babies. All the 300 mothers will be assessed.

  In pregnancy, weeks 6 and 24 months after delivery

• Maternal assessment of life stressful events

  The Life Stressful Events Questionnaire tool will be used to assess the impact of stressful life events (frequencies and severity) on the mothers. Categories of stressful events: Personal events: * Death of a loved one * Divorce or separation * Serious illness or injury * Job loss * Family Events: * Family member illness * Marital problems * Birth of a child * Changes in family structure Social Events: * Moving to a new location * Change in social status * Major life transitions (e.g retirement) Economic Events: * Financial difficulties * Significant changes in income or employment status Environmental Events: * Natural disasters * Major accidents Higher scores or frequency of reported stressful events are typically associated with increased levels of stress and potential negative health outcomes. Tool helps identify individuals who may benefit from further support or intervention based on their stress levels.

  In pregnancy, weeks 6 and 24 months after delivery

• Maternal sleep quality measurements

  Sleep quality will be measured as * Total sleep duration (time in hours from sleep onset to final waking) * Sleep onset latency (time in minutes from bedtime to the first 20-minute period of sleep) * Sleep efficiency (ratio of total sleep duration to total time spent in bed (hours) Classification into 3 groups by duration of sleeping; -Short sleep duration: Generally defined as less than 6 hours per night. Associated with increased risks for health issues, including fatigue, cognitive impairment, and mood disorders. -Adequate sleep duration: Defined as 7-9 hours per night. Considered optimal for good health, cognitive function, and overall well-being. -Long sleep duration: Defined as more than 9 hours per night. Should also be considered together with other factors such as sleep efficiency, sleep disturbances etc for a more comprehensive assessment. All the 300 mothers will be assessed.

  In pregnancy, weeks 6 and 24 months after delivery

• Maternal empowerment status using SWPER tool

  The empowerment status of women may influence how they care for their infants, ultimately affecting infant mortality and morbidity. Domains to be assessed; * Social independence * Decision making in house hold matters * Attitude towards violence A total of 14 items in the above SWPER 3 domains will be assessed. Standard cut points to categorize scores into low, medium, and high levels of empowerment will be used and correlated with infant health. All the 300 mothers will be assessed.

  In pregnancy, weeks 6 and 24 months after delivery

• Women's marital satisfaction status using Kansas tool

  Marital satisfaction status of women may influence how they care for their infants, ultimately affecting infant mortality and morbidity. The main question; 'How satisfied are you with your marriage?' Two more related questions are also asked. The responses to all the 3 questions are a seven-point Likert scale (1 = 'Extremely dissatisfied'; 2 = 'Very dissatisfied'; 3 = 'Somewhat dissatisfied'; 4 = 'Mixed'; 5 = 'Somewhat satisfied'; 6 = 'Very satisfied'; 7 = 'Extremely satisfied'). Score will range from 3 to 21, with a higher score indicating greater marital satisfaction and will be correlated with infant health. All the 300 mothers will be assessed.

  In pregnancy, weeks 6 and 24 months after delivery

• Concentrations of infant gut intestinal inflammation

  Infant stool will be quantified using ELISA or multiplex immunoassay for the following platforms: * Fecal calprotectin (intestinal inflammation) Comparison between infants born to mothers with different nutritional statuses (MUAC ≤23 cm vs. 25-35 cm) and exposed to either improved or poor WASH environments during pregnancy. These comparisons aim to characterize the biological signatures of environmental enteric dysfunction (EED), dysbiosis, and malnutrition, in the 4 groups. Unit of mesurement: Fecal calprotectin: µg/g stool•

  Stool samples at 12, 24, and 36 months of age

• Concentrations of infant intestinal permeability

  Infant stool will be quantified using ELISA or multiplex immunoassay for the faecal α1-antitrypsin and albumin. Biomarker concentrations will be compared between infants born to mothers with different nutritional statuses (MUAC ≤23 cm vs. 25-35 cm) and exposed to either improved or poor WASH environments during pregnancy. These comparisons aim to characterize the biological signatures of environmental enteric dysfunction (EED), dysbiosis, and malnutrition, in the 4 groups. Unit of measurements: Fecal α1-antitrypsin, albumin: mg/dL or µg/g.

  Stool samples at 12, 24, and 36 months of age •

• Infant fecal pH and fecal fat content

  Infant stool will be assessed for biomarkers of malabsorption and digestive efficiency. The van de Kamer test and/or non extractive method of nuclear magnetic resonance or infrared spectroscopy will be used measure fat in dried stool samples. A nitrazine paper strip will be used to measure pH of the stool samples Comparison between infants born to mothers with different nutritional statuses (MUAC ≤23 cm vs. 25-35 cm) and exposed to either improved or poor WASH environments during pregnancy. These comparisons aim to characterize the biological signatures of environmental enteric dysfunction (EED), dysbiosis, and malnutrition, in the 4 groups. Units of measurement; Fecal pH: pH units (1-7 scale) Fecal fat: % of stool mass.

  Stool samples at 12, 24, and 36 months of age •

• Infant systemic endotoxemia from gut leakage

  Infant serum lipopolysaccharide (LPS) will be measured using ELISA or multiplex immunoassay. Biomarker concentrations will be compared between infants born to mothers with different nutritional statuses (MUAC ≤23 cm vs. 25-35 cm) and exposed to either improved or poor WASH environments during pregnancy. These comparisons aim to characterize the biological signatures of environmental enteric dysfunction (EED), dysbiosis, and malnutrition, in the 4 groups. Unit of measurement; Serum LPS: ng/mL

  Stool samples at 12, 24, and 36 months of age •

• Percentages of circulating T and B lymphocyte subsets and natural killer

  PBMCs will be isolated from peripheral blood samples of infants at 6, 12, 24, and 36 months of age. Multicolor flow cytometry will be used to quantify the percentages of : * CD4⁺ and CD8⁺ T lymphocytes * Regulatory T cells (CD4⁺CD25⁺FOXP3⁺) * CD19⁺ B cells * CD56⁺ natural killer (NK) cells Comparisons will be stratified by maternal nutritional status (MUAC ≤23 cm vs. MUAC 25-35 cm) and household water, sanitation, and hygiene (WASH) exposure (better vs. poor WASH conditions). Arm/Group title: Children will be assigned to 4 groups defined by maternal nutritional status (MUAC ≤23 cm vs. 25-35 cm) and household WASH conditions (improved vs. poor) at the time of pregnancy. Overall number of participants: 300 children

  Infant blood samples collected at 12, 24, and 36 months of age. Expected measures/ Unit of measures: Percentage (%) of total PBMCs per cell subset (e.g., % CD4⁺ T cells, % CD56⁺ NK cells)

• Metabolic dysregulation and vaccine immune responses in infants presenting with malnutrition

  Investigators hypothesise that there is presence of metabolic dysregulation in malnourished infants further exacerbating this condition. Peripheral blood mononuclear cells of malnourished babies, including their matched normo-nourished counterparts will analysed using flow cytometry to characterise natural killer (NK) cells important in early life immunity and measure fatty acid uptake (BODIPY FL C16), glucose uptake and mitochondrial mass \[MitoTracker Green (MTG)\]. Granzyme B and perforin levels will be correlated with mean fluorescence intensity (MFI) MTG of NKG2A+/-CD56 dim and bright NK cells. All malnourished babies and theirs controls will be assessed, these results will be correlated with humoural standard EPI vaccine immune responses (titres).

  weeks 48, 96 and 144 old.

• Short and long term relationship between presence and frequency of early life diarrhea episodes and infant malnutrition, neurodevelopment and mental health

  The prevalence and incidence of diarrhea, including recovery cycles will be determined in infants born of malnourished /normonourished women in pregnancy living relatively better/poor WASH conditions. Diarrhea episodes will be defined as any episode of acute diarrhoea (≥3 passages of loose stool for 24 hours as reported by the mother) occurring before the next study visit In stool samples we will assess intestinal pathogens (viruses, parasites, bacterial pathogens). Plating of stool samples on McConkey agars and Enterobacteria will be further characterized using standard and advanced microbiology tools including full-length sequencing if possible. Intestinal helminthes ova will be assessed using Kato Katz smear of 41.7mg stool and calculate the number of egg count per 1gram stool.

  From birth and followed up to 3 years of age

• Intestinal leakage of severely malnourished babies

  In all severely malnourished 50% of matched infants without malnutrition, a lactulose/ rhamnose permeability test will be done. Weight-for-length/height below -3 standard deviations from the median with bilateral pitting edema and mid-upper arm circumference (MUAC) measurement below 110 mm in children aged 12-36, according to the World Health Organization definition of severe malnourished. Following drinking the sweet solution the urine will be periodically collected by the Study Gastroenterologist, and samples will stored appropriately. Mass spectrometry assessments of urine will be done in Switzerland.

  From 1 years old up until 3 years of age

• Intestinal calory extraction in severely malnourished babies

  In a subset of randomly chosen infants (20 with malnutrition and 20 matched infants without malnutrition), total calory extraction will be assessed longitudinally. Following consuming a specified diet, where the weight of the food will be accurately measured mothers will collect total infant stool for 24 hours on two subsequent days, using specific diapers. Analysis of remaining calories in infant stool samples will be done in Bern, Switzerland where a bomb calorimetry is available.

  Weeks 48, 96 and 144 old regardless of whether or not the babies recover from malnutrition.

• Colonisation patterns of Clostridioides difficile in Zimbabwe and Switzerland maternal-infant dyads

  To compare the differential impact of infant intestinal Clostridioides difficile colonization in Zimbabwe and Switzerland maternal-infant dyads.

  From birth and followed up every 6 months up until 3 years of age

• Intestinal inflammation assessment via endoscopy

  All infants with severe malnutrition and 50% randomly selected infants with moderate malnutrition will be offered endoscopy. Gastroscopy/rectosigmoidoscopy with general anesthesia will be done by the study Gastroenterologist. During endoscopy, biopsies will be acquired for histopathological assessment by the histopathologist, as well as assessment of inflammation and the intestinal microbiota.

  Any affected babies from one year of age

Secondary Outcomes (7)

• Concentrations of anti-Gal natural antibodies and memory B cell frequencies in infant blood and stool across early life

  Infant blood, serum, and stool samples at 3, 6, 12, 24, and 36 months of age.• Serum anti-Gal IgG, IgA, IgM: µg/mL• Stool anti-Gal IgA, IgM: µg/g• Memory B cell frequency specific to α-gal: % of total B cells or spot-forming units (SFU) per 10⁶ PBMCs

• Serum concentrations of anti-Gal antibodies

  Infant serum samples at 3, 6, 12, 24, and 36 months of age.

• Stool concentrations of anti-Gal antibodies

  Infant serum samples at 3, 6, 12, 24, and 36 months of age.

• Frequency of anti-Gal-specific memory B cells

  Infant PBMCs at 12, 24, and 36 months of age.

• Correlation of neonate mortality/morbidity and the presence of group B streptococcus (GBS)

  Neonates from pregnancy up to 6 weeks of age

Study Arms (4)

Group 1; Malnourished pregnant women, improved WASH living conditions

Malnourished, improved WASH: Pregnant women (≥20 weeks) with MUAC ≤23 cm, residing in improved WASH area (Kuwadzana research site, Harare)

Other: Malnutrition in pregnancy as exposure

Group 2; Normo-nourished pregnant women, improved WASH living conditions

Normo-nourished women, improved WASH living conditions: Pregnant women (≥20 weeks) with MUAC 25-35 cm and Hb ≥11 g/dL, residing in improved WASH area (Kuwadzana research site, Harare)

Group 3; Malnourished pregnant women, poor WASH living conditions

Malnourished women, poor WASH: Pregnant women (≥20 weeks) with MUAC ≤23 cm, residing in poor WASH area (Hopley research site, Harare)

Other: Malnutrition in pregnancy as exposure; Other: Poor WASH living conditions as exposure

Group 4; Normo-nourished pregnant women, poor WASH living conditions

Normo-nourished women, poor WASH: Pregnant women (≥20 weeks) with MUAC 25-35 cm and Hb ≥11 g/dL, residing in poor WASH area (Hopley research site, Harare)

Other: Poor WASH living conditions as exposure

Interventions

Malnutrition in pregnancy as exposure OTHER

MUAC ≤23 cm in pregnancy at least 20 weeks gestational age

Group 1; Malnourished pregnant women, improved WASH living conditions; Group 3; Malnourished pregnant women, poor WASH living conditions

Poor WASH living conditions as exposure OTHER

Poor water (source, quality, access, reliability), sanitation (toilet type, cleanliness, number of people using toilet) and personal (hand wash practices) and household hygiene (dumpster availability and emptying frequency) index scores. WASH Index score ranges; 1.Basic services (76-100%), 2.Semi-basic services (51-75%) 3.Poor services (26-50%) 4.No services (0-25%)

Group 3; Malnourished pregnant women, poor WASH living conditions; Group 4; Normo-nourished pregnant women, poor WASH living conditions

Eligibility Criteria

• Age: 18 Years+
• Gender Eligibility Details: Biological
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64), Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

Pregnant women at least 20 weeks gestational age seeking antenatal care services at any of the two primary health care centres, Kuwadzana and Hopely.

You may qualify if:

• MUAC ≤23 cm in pregnancy
• ≥18 years' old
• At least 20 weeks' gestational age
• Height ≥150 cm
• Planning to be staying in the study area for the next 3 years
• Willing to participate and comply with all study requirements and procedures.
• Age, HIV status, gestational age at enrolment, and area residence matched normo-nourished peers with MUAC ≥25 - ≤35 cm
• Haemoglobin level of ≥11g/dL
• ≥18 years' old
• At least 20 weeks' gestational age
• Height ≥150 cm
• Planning to stay in the study area for the next 3 years

You may not qualify if:

• Presence of severe mental health disorders interfering with study procedures according to the judgment of the investigator.

Sponsors & Collaborators

• University of Zimbabwe: lead
• University of Bern: collaborator
• Insel Gruppe AG, University Hospital Bern: collaborator
• LMU Klinikum: collaborator

Study Sites (1)

University of Zimbabwe

Harare, Zimbabwe

RECRUITING

Related Publications (32)

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Biospecimen

Retention: SAMPLES WITH DNA

Blood Breast milk Stool Mid stream urine

MeSH Terms

Conditions

Child Nutrition Disorders; Malnutrition; Dysentery; Infant Death

Interventions

Pregnancy

Condition Hierarchy (Ancestors)

Nutrition Disorders; Nutritional and Metabolic Diseases; Gastroenteritis; Gastrointestinal Diseases; Digestive System Diseases; Intestinal Diseases; Death; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Intervention Hierarchy (Ancestors)

Reproduction; Reproductive Physiological Phenomena; Reproductive and Urinary Physiological Phenomena

Study Officials

• Kerina Duri, Phd

  University of Zimbabwe

  PRINCIPAL INVESTIGATOR

• Exnevia Gomo, PhD

  University of Zimbabwe

  STUDY DIRECTOR

Central Study Contacts

Kerina Duri, PhD

CONTACT

+2634791631; kerina.duri@gmail.com

Patience Kuona, PhD/MD

CONTACT

+2634791631; patiekuona@gmail.com

Study Design

• Study Type: observational
• Observational Model: CASE CONTROL
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: July 18, 2025
• First Posted: September 26, 2025
• Study Start: January 27, 2025
• Primary Completion (Estimated): December 31, 2029
• Study Completion (Estimated): December 31, 2032
• Last Updated: September 26, 2025

Record last verified: 2025-09

Data Sharing

• IPD Sharing: Will share
• Shared Documents: STUDY PROTOCOL, SAP, ICF
• Time Frame: When available
• Access Criteria: To be advised

Locations

ZI (1)