Kualitas MP-ASI, microbiota usus

dan tumbuh kembang anak

Prof. Dr. dr. Rina Agustina, M.Gizi

Department of Nutrition; and

Human Nutrition Research Center (HNRC) IMERI
Faculty of Medicine
University of Indonesia
2024
Schröder, 2020 Rina Agustina 2024
Microbiota function
1. Metabolic/nutritional
a. Vitamin production
b. Short-chain fatty acids (SCFAs)
c. Conversion of phytoestrogens/bile acids, etc.
2. Intestinal development
a. Epithelial proliferation, restitution (regeneration?)
b. Crypt development
c. Angiogenesis
3. Exclusion of pathogens
4. Innate immune regulation
a. Modulation of cytotoxic response
b. Enhanced recognition and destruction of pathogens
5. Adaptive immune regulation
a. Development of tolerance

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Mechanisms of host defence against and tolerance to intestinal microorganisms.

80% of the immune system is found

in the area of the intestinal tract

The intestinal immune system is referred as GALT (gut-

associated-lymphoid tissue), which consists of Peyer’s patches,
which are units of lymphoid cells, single lymphocytes scattered in
the lamina propria and intraepithelial lymphocytes spread in the
Bron et al, 2012 Nature Reviews Microbiology 10, 66-78 intestinal epithelia.

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 Age-related changes in the human gut microbial ecosystem
Potential factors that could affect microbiota composition at different stages of life

• Diversity: species
(taxa) richness
within a single
host/microbial
environment;

• Diversity: diversity
in microbial
community
(taxonomic
abundance
profiles) between
different
environments/sam
ples)

Nagpal, 2018 Rina Agustina

5 2024
Exposure to microbes
in early life
• Gut microbiota constitutes a complex ecosystem
involved in physiologic functions critical for human
life
• A critical stimulus for the adequate maturation of
the immune system, which contributes to reducing
infections and aberrant immune responses.
• Exposure to microbes in early life, which largely
occurs through the microbial colonization of the
newborn intestine, has been related to
susceptibility to infections and sensitization to
environmental antigens in early and later life.

Sanz, 2011
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 Development of the gut microbiota in early life

a Development of gut microbiota diversity with age

b Development of the average gut microbiota composition with age, showing the relative abundance of the
major microbial families/orders

Ann Nutr Metab. 2021;77(Suppl. 3):21-34. doi:10.1159/000517912

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 Factors influencing the gut microbiota in early life

• Complementary feeding period

(6–24 months of life) coincides
with a critical period in gut
microbiota development,
transitioning away from the
influence of milk-based diet.

• As early childhood development

of a mature and diverse adult-like
gut microbiota, which is stable
and resilient toward perturbation,
appears to be an important asset
of health

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Ann Nutr Metab. 2021;77(Suppl. 3):21-34. doi:10.1159/000517912
Pathways of fetal programming of overweight through the microbiome

Kozyrskyj eta l 2015

(a) Potential mechanisms involved in the programming of obesogenic fetal and infant gut microbiota. (b)
Postnatal factors influenced by maternal overweight that may modify infant gut microbiota.
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 Micronutrient Deficiency as a Modulator of Gut Microbial Ecology

• The human gastrointestinal

microbiota has an essential role in
metabolism and cognition, thus
influencing vital functions of the
human body.
• The balance in our diet and
nutrients influences the healthy
growth of the microbiota in the first
years of life
• Micronutrient deficiencies during
the critical first 1000-day window in
children may lead to an impaired
mature gut microbiota with an
abnormal community structure and
expressed functions
Mach and Clark, 2017
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 Early Infancy Feeding and Gut Microbiota
A. Breast milk contains HMOs, which upon
ingestion by the infant pass undigested
through the upper GI tract until they reach
the colon. Here, they are digested by specific
HMO-degrading Bifidobacterium species into
various metabolites with potential beneficial
health effects.

A. Formula milk contain excess proteins, some

of which, upon ingestion, is incompletely
digested and absorbed in the upper GI tract
and reaches the colon. Partly digested
protein, peptides, and individual amino acids
are metabolized by gut microbes, including
opportunistic pathogenic bacteria, such
as Clostridium and Enterobacteriaceae species
yielding various amino acid catabolites,
some of which have potential detrimental
health effects.

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Ann Nutr Metab. 2021;77(Suppl. 3):21-34. doi:10.1159/000517912
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 Prevalensi Stunting Balita Indonesia 2022: 21,6%
Masing-masing Kelompok Umur Memiliki Risiko

Lonjakan 1.6x angka prevalensi stunting pada saat transisi bayi

di bawah 24 bulan – perlu Makanan Pandamping Air Susu
Ibu (MPASI) – kaya protein hewani.
Continued breastfeeding
Breastfeeding,
due to the presence of HMOs,
promotes growth of beneficial
bifidobacteria in the infant gut, which
produces metabolites that may
contribute to prevention of GI
infections and support immune system
development

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Complementary Feeding and Gut Microbiota

During infancy (6 mo) milk-based feeding is no longer adequate to

cover the nutritional requirements of the infant. Therefore,
supplementation with additional foods, alongside milk-feeding, is
needed

Early complementary feeding (before 3 months of age) has been

linked to increased risk of GI and respiratory infections, obesity, and
allergies, but this may rather be attributed to shorter duration of
breastfeeding.

Late introduction to complementary feeding can also be

problematic as it may result in feeding problems, inadequate nutrition
and growth, and failure to induce oral tolerance

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 Early (vs. later) introduction of complementary foods was associated
with bacterial phyla composition and short chain fatty acids

Early introduction Complimentary

feeding

Low abundance SCFAs

including isobutyric acid,
valeric acid, isovaleric acid,
heptanoic acid, and hexanoic
acid

a major bacterial phyla at 3 and 12 months of age

b major SCFAs at 3 and 12 months of age, stratified by the timing of
introduction to complementary food
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Differding et al, 2020
Early (vs. later) introduction of complementary foods was associated with differential abundance of a
total bacterial amplicon sequence variants (ASVs) in the infant gut at 3 and 12 months of age
Early introduction to complementary
foods was significantly associated with
• higher relative abundance of 6
ASVs, including Akkermansia
muciniphilia, Lachnoclostridium
indolis, Bacteroides (sp.
unknown), Erwinia (sp.
unknown), Streptococcus (sp.
unknown), and Veillonella (sp.
unknown), and
• lower relative abundance of 7
ASVs, including Veillonella (sp.
unknown), Bilophila
wadsworthia, Erwinia (sp.
unknown), Bacteroides (sp.
unknown), Bifidobacterium (sp.
unknown), Streptococcus (sp.
unknown), and Dialister
succinicivorans.

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Differding et al, 2020
Complementary Feeding and Gut Microbiota

Remarks
• Animal-source foods, fruits and vegetables, and nuts, pulses and seeds
should be key components of energy intake because of their overall
higher nutrient density compared to cereal grains
• Starchy staple foods should be minimized. They commonly comprise a
large component of complementary feeding diets, particularly in low
resource settings, and do not provide proteins of the same quality as
those found in animal source foods and are not good sources of critical
nutrients such as iron, zinc and Vitamin B12.
• Many also include anti-nutrients that reduce nutrient absorption.
• When cereal grains are used, whole cereal grains should be prioritized,
and refined ones minimized.
• Care should be taken to ensure that pulses, nuts and seeds are given in a
form that does not pose a risk of choking.

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 Complementary Feeding and Gut Microbiota
Complementary feeding period coincides drastic changes in the gut microbiota

• Rapid decline in HMO-degrading Bifidobacterium species

• prominent increase in alpha diversity and appearance/bloom
in Bacteroidaceae, Lachnospiraceae, and Ruminococcaceae species
• increased complexity of the diet with the introduction of fibers from various
fruits, vegetables, cereals/porridge, and breads as well as new protein sources
that is, in the form of meats, dairy products, and legumes/lentils.
• As dietary fibers and secondly (incompletely digested) proteins/peptides are
the main sources of energy for gut microbes these macronutrients would be
expected to have most impact on the microbial composition.
• Carbohydrates (dietary fibers) are preferred energy-sources for microbes, but
in shortage of these a higher degree of proteolytic fermentation occurs in the
gut.
• The main catabolic end products of dietary fiber metabolism are the short
chain fatty acids (SCFAs) acetate, butyrate, and propionate, acetate is produced
in high quantities in early infancy (e.g., by Bifidobacterium, Lactobacillus, and
Enterobacteriaceae spp.), butyrate and propionate concentrations are initially
very low but increase with infant age
Laursen, 2021 Rina Agustina 2024
 Complementary Feeding and Gut Microbiota

• Complementary feeding increases gut

microbial diversity and production of BCFAs
and SCFAs with potential implications for
growth, neuro, bone, and immune
development.

• milk-based component is gradually replaced

by other foods such as meats and dairy,
fruits and vegetables, and bread and cereals,
which are directly and possibly indirectly
(through the gut microbiota) impacting
growth and development.

BCFAs, branched chain fatty acids; SCFAs, short chain fatty acids.

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Ann Nutr Metab. 2021;77(Suppl. 3):21-34. doi:10.1159/000517912
 Complementary Feeding and Gut Microbiota

These foods contain protein and dietary fibers

that
• modulate the infant gut microbiota
• increasing alpha diversity and the
abundance of key bacterial families that
produce SCFAs and BCFAs during
complementary feeding.

This “natural” development of the gut

microbiota and its metabolites is associated
with healthy growth, neuro, bone
development, and appropriate immune
system regulation.

BCFAs, branched chain fatty acids; SCFAs, short chain fatty acids.
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Ann Nutr Metab. 2021;77(Suppl. 3):21-34. doi:10.1159/000517912
 Complementary Feeding and Gut Microbiota

Disturbance and
succession:
Switch to
solid foods
As the gut
environment
changes,

so does the
microbial community

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 Gut microbiota composition in children with standard diets vs. special diets

• Mediterranean diet
can lead to higher gut
microbiota diversity

• an increase in
Bacteroidetes,
lactobacilli,
bifidobacteria, Faecali
bacterium spp., Clostri
dium cluster XIVa and

• decrease in Firmicutes
and Proteobacteria

↓= decrease in family/genus or
phylum; ↑ = increase in
genus/family or phylum.

Profio et al 2022 Rina Agustina 2024

Microbial and metabolic changes in the colonic lumen after oral iron
administration
• Orally administered iron has a direct
impact on alteration of microbial
composition in the gut
• It can result in reduction in the beneficial
microbiota and the expansion of
pathobionts (A), and this can also provide
an opportunity for the expansion of enteric
pathogens (B).
• Not surprisingly, iron can promote the
replication and virulence of gut enteric
pathogens including Salmonella, Shigella,
and Campylobacter
• a heme-rich diet decreased gut microbial
diversity
Yilmaz and Li, 2018
Key Bacterial Taxa at Different Stages of 1000 Days That Contribute to Healthy versus
Undernourished Growth
• Healthy growth is associated with
greater Bifidobacterium
longum and Streptococcus thermophilus in
the first 6 months of life, which are less
prevalent in early-life undernutrition.

• Breastfeeding during this period is

associated with
greater Bacteroides and Bifidobacterium.
In later childhood, higher Akkermansia
muciniphila, Methanobrevibacter smithii,
Faecalibacterium prausnitzii, Lactobacillus,
and obligate anaerboes are associated
with healthy growth, whilst Escherichia
coli, Staphylococcus aureus and other
species are associated with severe acute
malnutrition.

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 Plausible links between complementary feeding (CF),
the gut microbiota, and child undernutrition
(A) Inadequate CF is associated with child
undernutrition.
(B) Significant changes in the gut microbiota
occur during the CF period. The introduction
of new food components and the age of
introduction and composition of the
complementary food influence the gut
microbiota.
(C) Gut microbiota disruptions are associated
with, and causally linked to, child
undernutrition. A bidirectional relation is
plausible where a disrupted gut microbiota
can cause undernutrition and vice versa. (D)
Interventions for undernutrition targeting
the gut microbiota during the CF period are
promising.
Chehab et al 2021
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 Infant gut microbiota development may be causally linked to healthy growth
and protection against food allergies

a. Relative abundance of
bacterial phyla.
b. Significant different genera
in stunted and normal
children (LDA score > 3)
c. Weighted UniFrac model of
beta diversity.
d. Chao1 and Shannon index
of alpha diversity.

The statistically significant

difference was indicated by an
asterisk (ns not significant;
***p ≤ 0.001)
Gut microbiota composition in normal and stunted children
Rinanda et al, 2023
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 Probiotics - modulation of the gut microbiota composition
ACTIVE Psychobiotics
EXOGENEOUS
BACTERIA
STRAIN-SPECIFIC

GUT-LUNG AXIS

VIA DIET - AVAILABLE

ENDOGENOUS
BACTERIA
Metabolites

Vieira, et al 2016
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 Probiotics - FAO and WHO (2001) definition
“Live microorganisms, which when administered in
adequate amounts, confer a health benefit on the
host”
Essential:
• Microbial, Viable; Beneficial to health and
• Strain-specific
• Many different types of probiotic strains
• Each strain will provide a different set of benefits
• Lactobacillus spp and Bifidobacterium spp.
FAO– WHO 2001 Rina Agustina29
– -2020
 Study Flow and Design
3929 children from community registry

3150 children entered screening phase I

Agustina et al 2012 1343 children entered screening phase II

497 randomly assigned: 494 included

Low calcium milk Regular milk Regular milk calcium + Regular milk calcium +
(≈50 mg Ca/day) calcium Lactobacillus casei 431 L reuteri DSM 17368
(≈440 mg Ca/day) 5.108 CFU/day 5.108 CFU/day

124 126 120 124

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 Results
Agustina et al 2012 All diarrhea
-32%

WHO-defined diarrhea
Adjusted Cox
survival curves
Particularly strong effect in
-24% children with lower
nutritional status

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 Probiotics and child growth
Few trials have focused on the role of probiotics in the improvement of
growth in community settings in low and middle income countries.

↓ Diarrhoea

↑ Absorption of
nutrients
Probiotics GROWTH
↑ Immunity

Growth Hormone
Agustina et al, 2013 stimulation
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 The effects of calcium and the probiotics
on the children’s growth and nutritional status?

Growth
• Height and weight gain (velocity)
Monthly
• Changes in height- and weight-for-age z scores (WHO)

• Changes in prevalence of wasting and stunting

Nutritional status
• Changes in anemia prevalence
Base- and
Endline
• Changes in iron status (serum ferritin, sTfR)
• Changes in zinc status (serum Zn)
• Serum hs-CRP and AGP
• Routine hematology
• Nutrient intake (FFQ) Probiotics can improve digestibility and nutritient
uptake of intestinal cells especially when
malnourished
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 Changes in nutritional status: Dietary nutrient intake
Shown are baseline results and change at endline if significant

Variable Low Ca Regular Casei Reuteri

(m±SD, or median and IQR) 123 126 120 123

Dietary intake
Energy (kcal/d) 1026 ± 365 1066 ± 329 1024 ± 369 977 ± 311
Protein (g/d) 34 ± 14 36 ± 13 34 ± 14 33 ± 11
Iron (mg/d) 5.9 (4.0, 7.6) 6.1 (4.7, 8.0) 5.5 (4.2, 7.3) 6.0 (4.6, 7.4)
Zinc (mg/d) 4.0 (2.9, 5.5) 4.8 (3.5, 5.7) 3.6 (2.9, 5.9) 4.3 (3.1, 5.4)
Calcium (mg/d) 231 (161, 230) 232 (165, 335) 205 (148, 305) 220 (158, 304)
Change (EL-BL, p<0.05) +1 (-101, 49) +354 (267, 440) +394 (292, 458) +382 (275, 455)
Fecal excretion
Calcium (mg/g dry) 7.6 (4.7, 11.1) 7.5 (4.8, 10.4) 6.6 (4.8, 9.3) 7.8 (5.1, 11.4)
Change (EL-BL, p<0.05) +0.4 (-2.0, 4.3) +15.9 (6.5, 23.9) +14.9 (7.1, 23.4) +15.1 (6.7, 20.7)

Shown are baseline results and change at endline if significant Rina Agustina 2024
 Group- and time-specific changes in height-for-age and
weight-for-age z score (Agustina et al 2013)

Rina Agustina 2021 Rina Agustina 2024

 GROWTH RESULTS
Variable Low calcium RC Casei Reuteri
124 126 120 124
Change
Weight, kg/6 mo 1.02 ± 0.8 0.96 ± 0.7 1.15 ± 0.9 1.16 ± 0.7*
Height, cm/6 mo 3.4 ± 0.9 3.3 ± 0.9 3.2 ± 0.9 3.5 ± 1.2
WAZ, score/6 mo 0.07 ± 0.3 0.06 ± 0.3 0.11 ± 0.4 0.14 ± 0.3*
HAZ, score/6 mo 0.15 ± 0.2 0.14 ± 0.2 0.12 ± 0.2 0.18 ± 0.3
Velocity
Weight, kg/mo 0.15 ± 0.1 0.14 ± 0.1 0.17 ± 0.2 0.17 ± 0.1*
Height, cm/mo 0.56 ± 0.1 0.54 ± 0.1 0.53 ± 0.2 0.57 ± 0.2*
WAZ, score/mo 0.003 ± 0.05 0.005 ± 0.05 0.01 ± 0.06 0.01 ± 0.05
HAZ, score/mo 0.02 ± 0.03 0.02 ± 0.03 0.02 ± 0.04 0.03 ± 0.05
At baseline At endline LC RC Casei Reuteri
31% stunted -5% -4% -7% -10%
23% underweight +1% -5% +2% -5%
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 CHILDREN Iron status
Variable LC RC Casei Reuteri
(n=123) (n=124) (n=120) (n=122)
Blood parameters (m±SD, or median and IQR)
HB (g/L) BL 12.0 ± 1.12 11.8 ± 1.35 12.0 ± 1.07 11.9 ± 1.04
Change -0.19 ± 0.77 -0.15 ± 0.88 -0.25 ± 0.77 -0.14 ± 0.75
Serum ferritin (µg/L) BL 18.3 (9.7, 30.7) 24.4 (9.3, 39.1) 22.8 (12.0, 35.3) 19.5 (11.6, 32.4)
Change -4.0 (-11.1, 1.0) -4.4 (-15.7, 1.6) -4.2 (-13.5, -0.4) -3.7 (-11.5, 0.9)
Serum TfR (µg/L) BL 8.1 (6.5, 10.4) 8.5 (6.6, 10.4) 8.4 (6.9, 10.6) 8.5 (6.8, 10.2)
Change 0.9 (-0.35, 1.7) 0.9 (-0.6, 2.2) 0.4 (-0.6, 1.9) 0.7 (-0.3, 2.0)
Prevalence of anemia and iron deficiency
Anemia (%) BL 19 26 20 19
(Hb<11.5-12 g/dL) Change +2 +1 +2 +1
Iron deficiency (%) BL 32 33 27 30
(Ferritin <12-15 µg/L) Change +2 +2 +2 +2
Iron def. anemia (%) BL 10 14 11 11
(Anemia + Fe def.) Change +3 +3 +4 +2

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 CHILDREN Zinc status
Variable Low calcium RC Casei Reuteri
109 116 116 117

Serum Zinc (µmol/L), (m±SD)

BL 8.50 ± 2.47 8.42 ± 2.24 8.78 ± 2.72 8.70 ± 2.28
Change 0.34 ± 2.01 0.30 ± 2.45 -0.03 ± 2.23 -0.04 ± 1.95

Prevalence of zinc deficiency*, %

BL 71 78 65 68
Change -9 -7 +2 +6

*Serum Zn <9.9 µmol/L in non-fasted, morning blood sample

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 Conclusions on intervention effects on
the children’s growth and nutritional status

Growth
• L. reuteri DSM 17938 modestly improves growth by increasing
weight, height and weight-for-age z score
• L. casei 431 has a small positive effect on monthly growth
velocity in weight
• Calcium did not affect growth

Nutritional status
• The probiotic strains did not reduce anemia prevalence or
improve iron and zinc status
• Milk calcium did not negatively affect anemia prevalence or the
iron and zinc status

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Conclusion
• Early development of gut microbiota composition is
influenced by many factors, especially infant feeding
• Breastfeeding and diversed diet plays an important
role in shaping gut microbiota diversity
• Gut microbiota strongly affects child growth and health

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