Abstract

Background:

Early-life dysbiosis associated with Cesarean section (C-section) delivery is increasingly recognized as a modifiable risk factor influencing short- and long-term health outcomes. This multidisciplinary expert consensus summarizes the clinical implications of C-section on infant gut microbiota. It proposes evidence-based strategies to mitigate these effects, with a focus on the critical window of the first 1,000 days of life.

Methods:

A multidisciplinary panel of 16 pediatricians, neonatologists, pediatric gastroenterologists, and nutrition experts conducted a targeted narrative review of the literature to inform a structured expert consensus process and participated in an online structured consensus process. Seventeen consensus statements were developed and validated through discussion, expert voting, and commentary, supported by a targeted review of current scientific evidence.

Results:

The expert panel reached consensus on the impact of C-section delivery on early microbiota composition and its clinical relevance, emphasizing that the rising prevalence of C-sections worldwide demands urgent attention. Experts unanimously emphasized the importance of exclusive breastfeeding as the primary strategy to support healthy microbiota development in infants born by cesarean section. When exclusive breastfeeding is not possible, evidence-based nutritional approaches, including selected prebiotics and probiotic strains with documented clinical efficacy, are recognized as promising alternatives for supporting microbial balance. Notably, the panel underscored that not all probiotics are equally effective and recommended shifting toward evidence-based strains shown to help restore gut dysbiosis in this population. Also, experts advocated for continuing microbiota-targeted support throughout the first 1,000 days of life, viewing this developmental window as a critical continuum rather than a limited early-life phase, while acknowledging the need for more long-term data. Additionally, education for healthcare professionals and parents about the long-term implications of C-section delivery was emphasized as a key enabler of the broader adoption of eubiosis-targeted strategies.

Conclusions:

Optimizing microbial colonization in infants born by cesarean section requires a multifaceted approach that prioritizes breastfeeding, supports judicious use of evidence-based nutritional interventions when needed, and emphasizes education and continuity of care across early life. By aligning clinical practice with emerging microbiome science, early-life interventions may reduce dysbiosis-associated risks and improve long-term health outcomes.

1 Introduction

The establishment of a diverse and balanced gut microbiota in the first 1,000 days of life—from conception through early childhood—is a critical determinant of long-term health, playing a central role in immune reprogramming, metabolic regulation, micronutrient absorption, and the physiological maintenance of epithelial integrity (1–3). Microbial colonization in early life is shaped by several perinatal factors, including mode of delivery, infant feeding practices, maternal-infant interactions, antibiotic exposure, and environmental exposures. Disruptions in microbial colonization during this window—particularly those associated with Cesarean section (C-section) delivery—have been linked to increased susceptibility to adverse health outcomes later in life (4, 5). Given this long-term importance of early normal microbial colonization, maintaining or restoring a healthy gut microbiome in early life has become a priority for healthcare professionals (HCPs).

According to the Developmental Origins of Health and Disease (DOHaD) framework, early environmental exposures during sensitive developmental windows, particularly the first 1,000 days, can permanently shape physiological systems and increase the susceptibility to non-communicable diseases (NCDs) (6). Among these influences, the mode of delivery is a key determinant of early microbial colonization. Vaginal delivery enables the vertical transmission of maternal vaginal and fecal microbiota, including Bifidobacterium, Lactobacillus, and Bacteroides species, crucial to neonatal immune and metabolic development (5, 7). In contrast, C-section delivery is associated with altered colonization by maternal skin- and hospital-associated microbes, such as Staphylococcus, Klebsiella, and other opportunistic species, as well as the delayed establishment of beneficial taxa, including short-chain fatty acid (SCFA)–producing bacteria (8, 9). This delayed colonization of the infant-type microbiota and reduced microbial diversity may persist for months to years and is commonly described as early-life dysbiosis (10, 11).

The altered microbiota seen in infants born by cesarean section represents a potential risk factor for increased risk of infections and for a range of NCDs, including allergic diseases, atopic dermatitis, food allergies, asthma, obesity, type 1 diabetes, and selected neurodevelopmental disorders (12–16) These associations are thought to be mediated, at least in part, by immune dysregulation and heightened inflammatory responses linked to disrupted early colonization (17, 18).

Critically, breastfeeding remains the most effective and physiologically appropriate intervention for the development of a healthy infant microbiota and for promoting immune tolerance (19, 20). However, when breastfeeding is not possible or is insufficient, nutritional approaches specifically tailored to infants born by cesarean section—such as infant formulae fortified with prebiotics, probiotics, or synbiotics—may help mitigate the impact of dysbiosis, particularly if designed to promote colonization by beneficial bacteria such as Bifidobacterium and Lactobacillus (21–24).

Furthermore, emerging evidence supports a continuity-based approach: interventions should not be limited to the neonatal period but extended across the full 1,000-day window to maximize long-term health benefits. The concept of “microbial care continuity” is emerging as an essential framework for proactively addressing the evolving needs of the infant microbiome and in alignment with developmental milestones (3, 25).

Despite growing evidence, current clinical practices and guideline recommendations related to microbiota support in infants born by cesarean section remain heterogeneous. To address this gap, Danone MENA convened a multidisciplinary expert panel of regional pediatricians, neonatologists, pediatric gastroenterologists, and nutrition specialists to develop evidence-informed, consensus-based guidance on how to best mitigate the microbiota-related health consequences of C-section delivery. This consensus document outlines the panel's key statements and practical recommendations, with an emphasis on breastfeeding as the foundational intervention, targeted nutrition, evidence-based use of synbiotics, and educational outreach.

2 Materials and methods2.1 Expert selection process

To develop this multidisciplinary consensus, a panel of 16 experienced practicing clinicians and researchers from Bahrain, Italy, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates participated in an online consensus meeting. The panel included pediatricians, neonatologists, pediatric gastroenterologists, and nutrition experts with deep clinical experience in managing the health of infants born by cesarean section. Selection was based on recognized expertise in microbiome research, neonatal and infant nutrition, and regional insights into delivery practices. The diversity of the panel ensured a comprehensive understanding of the biological, clinical, and practical dimensions of early-life microbial modulation, with a focus on breastfeeding advocacy, precision in the use of prebiotics and probiotics, and long-term health considerations throughout the first 1,000 days. All experts participated voluntarily and contributed independent clinical judgment.

2.2 Evidence review and statement formulation

This work represents a multidisciplinary expert consensus statement supported by a targeted narrative literature review. Prior to the consensus meeting, Danone MENA, in collaboration with CCM International, conducted a targeted literature review to collate and summarize relevant scientific evidence for panel consideration. The targeted literature review included English-language, peer-reviewed studies focusing on human infants, particularly those delivered via C-section. Priority was given to randomized controlled trials, systematic reviews, and large observational cohort studies addressing microbiota composition, clinical outcomes, and nutritional interventions. Studies with insufficient methodological detail, non-human data, or a lack of relevance to predefined thematic areas were excluded. The compiled evidence focused on four predefined thematic areas:

The rising global and regional prevalence of C-section deliveries, which is above the recommended rates by the WHO.

The short- and long-term effects of C-section on infant gut microbiota composition and associated health outcomes.

Effective and evidence-supported nutritional strategies for supporting or restoring microbiota balance in infants born by cesarean section; and

The role of HCPs and parental education in adopting microbiota-supportive practices.

The expert panel was provided with a curated selection of relevant evidence identified through a targeted literature review. This approach aimed to prioritize high-quality, clinically relevant studies while ensuring the feasibility of the consensus process, rather than presenting the entire available literature. Draft consensus statements were developed in advance of the meeting based on current clinical practice, published evidence, and expert consultations. During statement formulation, specific attention was given to the following concepts:

The importance of breastfeeding as the optimal and foundational intervention for microbiota development in all infants (19, 20),

The efficacy of specific probiotic strains, when administered in combination with selectively utilized prebiotic substrates, in restoring microbiota profiles (e.g., Bifidobacterium breve M-16 V, Lactobacillus rhamnosus GG) (21, 24, 26),

The emerging scientific consensus on the importance of continuity of microbial support throughout the first 1,000 days, rather than limiting interventions to the neonatal period (3, 25).

These topics were selected to ensure the final recommendations reflected the evolving understanding that early-life dysbiosis is both modifiable and time-sensitive, and that targeted strategies must go beyond one-size-fits-all solutions.

2.3 Quantification of consensus and voting process among experts

Prior to the live consensus meeting, panel members independently reviewed and voted on each draft statement, using a three-point scale: “disagree,” “partially agree,” and “fully agree”. Out of the 16 experts, one member, the panel chair, did not participate in the voting to maintain neutrality. These votes provided a baseline for identifying areas of consensus and divergence. The percentage of experts selecting each option was calculated.

During the structured virtual meeting, the panel engaged in evidence-guided discussions of each statement, with opportunities to revise content for clarity, accuracy, or scope. The experts were encouraged to discuss each statement extensively within the group and amend it accordingly. At the end of the discussion, each panelist could reconsider their original assessment or provide their final comments. Finally, agreement and discussion among the experts were also recorded.

Following discussion and revision, a revote was conducted. A predefined agreement threshold of ≥75% was used to define consensus. This process ensured that the final expert recommendations reflected a high level of agreement, clinical applicability, and credibility for understanding the long-term effects of C-section on gut microbiota composition and existing mitigating strategies. Final recommendations were shared with all panelists for endorsement and represent a synthesis of scientific evidence and expert judgment, emphasizing breastfeeding as the first-line intervention, cautious use of synbiotics when appropriate, and the principle of continuity of microbiota care throughout early life. Figure 1 shows the consensus development flow diagram.

Structured consensus development process for generating multidisciplinary expert recommendations on infant gut microbiota following cesarean section. This figure illustrates the stepwise methodology used to develop the expert consensus. A targeted literature review was first conducted to identify relevant clinical and scientific evidence. Based on this evidence, draft statements were formulated and subjected to an initial round of voting by the expert panel using a predefined agreement threshold. Statements that did not reach consensus underwent structured discussion to refine wording and interpretation. Revised statements were then reassessed through a second round of voting (revoting). Final consensus was defined by achieving a predetermined level of agreement among panel members. This iterative process ensured that recommendations were evidence-informed, transparent, and reflective of multidisciplinary expertise.

The methodology aligns with established approaches to consensus-based recommendations, in which targeted evidence synthesis is integrated with expert interpretation to address clinically relevant questions in areas where high-quality randomized evidence may be limited. Specific probiotic strains or synbiotic formulations mentioned in this manuscript are provided as illustrative examples based on available clinical evidence and should not be interpreted as exclusive recommendations. Other formulations with comparable composition and supporting clinical data may also be appropriate.

3 Results3.1 C-section prevalence globally and in the Middle East

The expert panel reviewed current epidemiological data demonstrating a sustained global increase in C-section delivery rates, a trend considered increasingly concerning for infant health and microbiota development. According to the World Health Organization (WHO), global C-section rates surged from approximately 7% in 1990 to 21% in 2021, with projections suggesting a further rise to nearly 29% by 2030 (27). These figures exceed the WHO-recommended threshold of 10%–15%, beyond which no additional reductions in maternal or neonatal mortality are typically observed (28).

This trend is particularly prominent across the Middle East, where C-section rates in several countries consistently exceed global averages. The panel reviewed regional data indicating that:

Egypt, Iran, and Turkey regularly reported rates exceeding 40% (27, 29).

In the United Arab Emirates, the national prevalence of C-sections reached 42.5% in 2021 (30), with notable inter-emirate variation, including rates of 15.4% in Dubai (31) in 2017 and 30.2% in Abu Dhabi (32).

Kuwait reported a rate of 35.3% in 2023 (33).

Lebanon documented a rate of 49.5% in 2019 (34).

Oman reported 23.6% in 2022 (35).

Qatar experienced an increase from 16.3% in 1998 to 29.8% by 2013 (36).

KSA-based studies reported rising C-section rates ranging from approximately 19% in public hospitals to over 30% in urban settings (37, 38).

The panel unanimously agreed that this rising prevalence represents a global public health concern, especially in the context of microbiota-mediated health outcomes. Such variability across countries was considered to reflect a multifactorial interplay of healthcare system infrastructure, medical practice patterns, socioeconomic factors, maternal preferences, and cultural influences. Nonetheless, a consistent regional pattern of rising C-section utilization was identified, including procedures performed in the absence of clear medical indications.

The panel emphasized that these regional trends amplify the need for:

Clear, evidence-informed clinical guidelines to promote microbiota-conscious C-section practices.

Targeted education for both clinicians and parents regarding potential long-term health considerations.

And the integration of microbiota-supportive interventions, such as breastfeeding promotion and, when breastfeeding is not feasible, the judicious use of evidence-based synbiotics.

Ultimately, the panel reached complete consensus that increasing global and Middle Eastern C-section rates pose substantial challenges to neonatal gut health, underscoring the necessity of proactive, evidence-based strategies to safeguard infant microbiota development (

Table 1

).

No.StatementDisagreePartially agreeAgree1According to new research from the World Health Organization (WHO), C-section prevalence continues to rise globally0%0%100%2Related to global prevalence trends and local evidence, the overall prevalence of C-section in the Middle East region is clearly increasing0%6.67%93.33%

Expert consensus on C-section prevalence globally and in the Middle East.

Percentages are based on responses from 15 voting panel members. The full panel included 16 experts; the chairperson abstained from voting to maintain neutrality.

3.2 Early-life gut microbiome, C-section delivery, and its impact

The expert panel unanimously agreed that the mode of delivery is a major determinant of early-life gut microbiome, a relationship that is supported by a substantial body of clinical, epidemiological, and mechanistic evidence. Consequently, the first four of the evaluated statements of the present segment (Table 2), which addressed the distinct microbial composition in infants born by cesarean section, the reduced microbial diversity and dysbiosis, the associated long-term health risks, and the colonization by hospital-associated bacteria, were reinstated during the meeting, not merely as consensus-based statements, but as evidence-supported associations.

No.StatementDisagreePartially agreeAgree3The gut microbiome of a C-section-delivered baby differs from that of a infants born by vaginal delivery. The mode of delivery significantly impacts the composition of an infant's gut microbiome0%0%100%4C-section delivery appeared to decrease the diversity of gut microbiota in neonates, leading to dysbiosis0%0%100%5The compromised gut microbiota in C-section born babies is potentially linked to long-term health implications like immune-related disorders, obesity, and allergies, such as asthma0%0%100%6Based on evidence, newborns delivered by C-section tend to harbor in their gut potential pathogenic bacteria commonly found in hospitals (e.g., Enterococcus and Klebsiella) and mother's skin surface, and have inefficient levels of beneficial bacteria, as found in infants born by vaginal delivery (e.g., Bacteroides and Bifidobacterium species)0%6.67%93.33%7Bifidobacterium is considered a crucial taxonomic group in the early stages of intestinal microbiome development, being a predominant bacterium and among the primary colonizers in infants born by vaginal delivery.0%0%100%8The microbiota plays a fundamental role in the induction, training, and function of the host immune system0%0%100%9Current evidence suggests that early life, defined as the first 1,000 days, provides an opportunity for modulating the gut microbiota to promote long-term health.0%0%100%10Studies suggest that C-section might be a risk factor for developing functional gastrointestinal disorders (e.g., functional constipation, infantile colics…) due to the altered gut microbiota also called dysbiosis.0%6.67%93.33%11Based on evidence, C-section born babies have higher risk of infections0%13.33%86.67%12C-section is associated with delayed colonization of the Bacteroidetes phylum, and reduced diversity of total microbiota in the first five years after birth0%6.67%93.33%

Expert consensus on early-life gut microbiome, C-section delivery and its impact.

Percentages are based on responses from 15 voting panel members. The full panel included 16 experts; the chairperson abstained from voting to maintain neutrality.

More specifically, all voting panel members agreed (100%) that the gut microbiome of an infant born by cesarean section differs significantly from that of an infant born by vaginal delivery. In particular, C-section delivery was consistently associated with reduced gut microbial diversity in neonates, a hallmark commonly described as a marker of dysbiosis (39). Importantly, C-section delivery is associated with disrupted vertical transmission of maternal microbes and delayed colonization by beneficial species, predisposing infants to dysbiosis and its downstream effects. As such, the growing rate of surgical deliveries highlights the urgency of implementing preventive and restorative microbiota strategies, particularly in vulnerable populations.

Vaginal delivery is typically associated with early colonization by maternal vaginal and intestinal microbes, such as Lactobacillus and Bifidobacterium species, which have been shown to support gut and immune health by aiding digestion, producing SCFAs, and promoting immune tolerance (4, 40). By contrast, C-section delivery is more frequently associated with colonization by skin-associated and environmental microbes from hospital operating rooms (e.g., Staphylococcus, Corynebacterium), whose presence is considered a marker of dysbiosis (17, 20, 41, 42). The experts noted that this altered microbial profile is shaped during the neonatal period and can persist for several months, potentially impairing immune system maturation and influencing allergic, autoimmune, and metabolic outcomes in later life. On the other hand, they also acknowledged evidence that microbial diversity may partially normalize over time, particularly with breastfeeding or other supportive exposures. However, the panel noted that despite this potential recovery, the disruption occurs during a critical window of microbiota, immune, and gut development, raising concerns about possible long-term health implications.

To this end, the discussion next focused on long-term health issues that can arise from the altered gut microbiota observed in infants born by cesarean section, a fact supported by a large body of epidemiological and mechanistic evidence (43). Early disruptions in microbial exposure, such as C-section delivery or antibiotic administration, may result in an overreactive or underdeveloped immune system, leading to lasting effects (44). These can include immune-mediated, allergic, and metabolic conditions, such as asthma, atopic disease, obesity, and type 1 diabetes (12, 14, 43). Still, the panel cautioned that such associations can be influenced by multiple confounding factors, including host genetics, infant feeding practices, and antibiotic exposure (17, 20, 41). Accordingly, causality cannot be inferred from observational data alone. Furthermore, on a related point which had already briefly been discussed, 93.33% of the panel (Table 2) supported the statement that C-section newborns tend to harbor potentially pathogenic bacteria such as Enterococcus and Klebsiella, commonly acquired from hospital environments and maternal skin, thus reflecting the surgical mode of delivery and the higher likelihood of early antibiotic exposure, while having reduced abundance of taxa commonly observed in infants born by vaginal delivery (e.g., Bacteroides and Bifidobacterium spp.) (17, 41).

Following, the panel focused on the importance of Bifidobacterium as a predominant early colonizer in infants born by vaginal delivery who had breastfeeding. This genus contributes to the utilization of human milk oligosaccharides (HMOs), SCFA production, gut barrier integrity, and immune modulation; thus, Bifidobacterium was noted as crucial to the establishment of a protective and balanced gut ecosystem (19). Reduced colonization in infants born by cesarean section was acknowledged as a plausible contributor to various adverse health outcomes. Overall, the gut microbiota was unanimously (100%) agreed to play a fundamental role in the induction, training, and function of the host immune system. Evidence reviewed during the meeting demonstrated that early microbial exposures support the maturation of immune cells, help balance inflammatory responses, and promote tolerance to non-harmful antigens (18). From a mechanistic perspective, commensal microbes influence the development of gut-associated lymphoid tissue (GALT) and the production of immunoglobulin A (IgA), both of which are essential for immune homeostasis (45). Consequently, the panel emphasized that disruptions to this process may predispose infants to immune-mediated diseases. Critically, the panel emphasized that early life—particularly the first 1,000 days from conception to age two—represents a critical and time-sensitive window of opportunity for microbiota modulation to promote long-term health (25). Intervening during this period with breastfeeding, or when necessary, tailored nutritional strategies (e.g., prebiotics, probiotics, synbiotics), is essential for restoring microbial balance and promoting long-term health.

With respect to functional gastrointestinal disorders, a strong majority of experts (93.33%) agreed that C-section delivery may be associated with an increased risk of conditions such as functional constipation, infantile colic, and irritable bowel syndrome (IBS), although the evidence base was described as heterogeneous. Specifically, a large cohort study (JECS) reported a slight increase in functional constipation by age 3 among children born by C-section, yet infant colic has shown no consistent association with delivery mode (46, 47). These conditions may involve alterations in gut-brain axis signaling and immune regulation, potentially linked to early-life microbial composition (48). Reduced abundance of beneficial bacteria such as Bifidobacteria and Lactobacilli in C-section-born infants was discussed as a possible contributing factor (3, 47, 49). On a broader scale, the panel reached 86.67% agreement with the statement that infants born by cesarean section face an increased risk of infections (15, 50), with 13.33% partially agreeing, noting that the term “infection” encompasses heterogeneous outcomes (Table 2). The panel acknowledged moderate, consistent evidence suggesting a small but statistically significant increase of infections (especially respiratory and gastrointestinal) among C-section–born children, requiring hospitalization during early childhood (51). The association diminishes with age and may be influenced by many confounding factors (feeding mode, postnatal exposures, hygiene) (51, 52).

Finally, 93.33% of experts agreed that C-section delivery is associated with delayed colonization by the Bacteroidetes phylum and reduced total microbial diversity, which may persist for up to 5 years after birth 11,39. While recovery timelines vary depending on population, feeding, and antibiotic administration—with some studies noting recovery within 6–12 months (53, 54), given that Bacteroidetes play a key role in carbohydrate metabolism and the production of health-promoting SCFAs, such alterations in microbial colonization patterns may have lasting effects on gut and metabolic health (55, 56). Early interventions, particularly prolonged breastfeeding and, where appropriate, targeted nutritional strategies such as clinically supported microbiota-restoring formulas, were considered potential modifiers of these trajectories.

3.3 Nutritional strategies for restoring gut microbiota

The expert discussion reviewed nutritional strategies to support the development and restoration of a balanced gut microbiota in infants born via C-section. There was unanimous agreement that exclusive breastfeeding remains the optimal and most effective strategy for establishing a healthy gut microbiome, including in C-section–born infants. Breast milk promotes colonization by beneficial taxa, particularly Bifidobacterium species. It contains bioactive components such as human milk oligosaccharides (HMOs), present at a dosage of 12–15 g/L, with more than 1,000 structures of varying chain lengths, which provide the quantitative and structural diversity that selectively favors the establishment of beneficial microbes (57, 58). Moreover, secretory IgA and antimicrobial peptides, which are also present in breast milk, contribute to gut and immune development (19, 20). On this basis, the panel reaffirmed breastfeeding as the foundational microbiota-supportive intervention whenever possible.

In situations where exclusive breastfeeding is not feasible or sufficient, the panel emphasized the importance of using nutritional solutions specifically tailored to the needs of C-section–born infants. These solutions should be supported by robust clinical evidence and may include infant formulae supplemented with prebiotics, probiotics, or synbiotics that have demonstrated clinical efficacy in promoting beneficial microbial colonization and mitigating features of early-life dysbiosis, thereby mimicking the quantity, diversity, and functionality of breastmilk components. For example, probiotic strains such as Bifidobacterium and Lactobacillus, as well as symbiotic formulations combining prebiotics and probiotics, have been shown to mimic some of the microbial benefits of breast milk, thereby helping to reduce the risk of dysbiosis and supporting gastrointestinal and immune maturation (21, 24, 59). Notably, some experts have suggested that this time frame could be expanded to encompass the entire first 1,000 days of life, which defines early life, as this developmental period is a critical window for shaping microbiota composition and programming the immune system. In agreement with this suggestion, the panel unanimously agreed that microbiota-targeted nutritional interventions may be relevant beyond infancy and throughout the entire first 1,000 days of life, not just the first year, to achieve long-term health benefits. In conclusion, to the discussion of the above statements, the experts highlighted the importance of strategies such as prebiotic, probiotic, and synbiotic supplementation (1, 2). Importantly, the panel stressed that not all probiotics are equal and strongly recommended using only strains with documented efficacy in C-section populations to support infant gut health. Furthermore, given the role of prebiotics in modulating the infant gut microbiota, future consensus efforts could consider selection criteria such as compositional diversity, functional properties, and dosage. In this context, prebiotic blends such as short-chain galacto-oligosaccharides (scGOS) and long-chain fructo-oligosaccharides (lcFOS), provided at 8 g/L with approximately 100 structures and a short: long ratio of 9:1, have been recognized to closely resemble HMOs in complexity, diversity, and functionality, making them particularly relevant for infant nutrition (60).

The panel strongly endorsed a synergistic approach combining prebiotics and probiotics to help reestablish gut microbial balance in infants born by cesarean section. Specifically, 93.33% of experts agreed, and 6.67% expressed partial agreement. More specifically, carefully selected prebiotics, such as the scGOS/lcFOS blend, serve as substrates that selectively feed beneficial bacteria, while probiotic strains like Bifidobacterium breve M-16V contribute directly to colonization. Clinical evidence supports the use of combined supplementation in modulating the early gut environment of infants born by cesarean section (21, 24, 61). Notably, the panel highlighted recent studies showing that early supplementation with a specific synbiotic blend, comprising scGOS/lcFOS, and B. breve M-16V, may compensate for the delayed colonization of Bifidobacteria commonly observed in infants born by cesarean section (21, 24, 26). This intervention has been associated with a reduction in the abundance of potentially harmful species such as Clostridium difficile, enhanced acetate production, which is a beneficial SCFA, and the acidification of the intestinal environment—features consistent with a microbiota profile more commonly observed in infants born with vaginal delivery (21, 24, 26, 62) This early synbiotic blend supplementation with scGOS/lcFOS and B. breve M16-V in infants born by cesarean section allows a fast colonization by Bifidobacteria from the first days of life, which may accelerate microbial maturation and provide immune-modulating benefits (21, 24, 26). To this end, such supplementation contributes to creating a gut environment that more closely resembles that of infants born by vaginal delivery. Additionally, the panel advocated for a continuity-of-care model, in which microbiota-targeted interventions are extended beyond infancy and throughout the first 1,000 days of life (3, 25). This approach recognizes the ongoing development of the gut microbiota and immune system well into toddlerhood and aligns with the DOHaD principles.

In line with earlier discussions on immune development, the panel unanimously agreed (100%) that restoring the compromised microbiota in infants born by cesarean section may support immune tolerance, in turn potentially lowering the incidence of skin disorders (Table 3). Discussion focused on evidence linking early-life dysbiosis to altered immune regulation and increased susceptibility to allergic disease (63–65) The panel unanimously agreed that by reestablishing a more balanced microbial community, nutritional strategies may support immune tolerance, strengthen mucosal defenses, and reduce inflammatory responses, potentially lowering the incidence or severity of skin disorders (66).

No.StatementDisagreePartially agreeAgree13If exclusive breastfeeding is not possible, an evidence-based nutritional solution tailored for C-section-born babies should be considered to modify gut microbiota composition during the first year.0%0%100%14Some interventions to restore a perturbed microbial community might be efficient throughout the first 1,000 days0%0%100%15A combination of specific prebiotics and probiotics is supported by clinical evidence to help restore the gut microbiota in infants, and it may be a good option for nutritional supplementation in babies born by cesarean section.0%6.67%93.33%16Restoring the compromised gut microbiota in C-section born babies might improve some health outcomes, leading to reduced skin disorders (ex, atopic dermatitis, eczema)0%0%100%

Expert consensus on nutritional strategies for restoring gut microbiota.

Percentages are based on responses from 15 voting panel members. The full panel included 16 experts; the chairperson abstained from voting to maintain neutrality.

Overall, the expert panel endorsed early and targeted nutritional interventions, which can act synergistically (e.g., breastfeeding as the first-line strategy, synbiotic-enriched formulas when exclusive breastfeeding is not possible, and the targeted use of validated combination of prebiotics and probiotic strains), as key tools for modulating the infant microbiome in vulnerable populations, such as infants born by cesarean section, to support beneficial microbial colonization, immune maturation, and long-term health. Emphasis was placed on adopting a longitudinal perspective that addresses microbial development throughout the full 1,000-day window of opportunity.

3.4 The role of education

The expert panel unanimously agreed that education represents a central and enabling component of strategies aimed at addressing the potential long-term health implications associated with C-section–related dysbiosis (Table 4). Providing HCPs and parents with evidence-based information was considered essential to support the appropriate adoption of microbiota-supportive feeding practices during the critical early-life window. A key concern identified during the panel discussion was the persistence of misconceptions regarding microbiota-targeted interventions, particularly the assumption that all probiotic products confer equivalent benefits. The panel emphasized that educational initiatives should clearly communicate the strain-specific nature of probiotic effects and underscore that only clinically validated strains—such as Bifidobacterium breve M-16V—have demonstrated efficacy in restoring microbiota balance in this population when combined with scGOS/lcFOS.