Diarrheal illness in a cohort of children 0-2 years of age in rural Bangladesh: I. Incidence and risk factors

Is the impact of paid maternity leave policy on the prevalence of childhood diarrhoea mediated by breastfeeding duration? A causal mediation analysis using quasi-experimental evidence from 38 low-income and middle-income countries

OBJECTIVES

Quasi-experimental evidence suggests that extending the duration of legislated paid maternity leave is associated with lower prevalence of childhood diarrhoea in low-income and middle-income countries (LMICs). This could be due to a variety of mechanisms. This study examines whether this effect is mediated by changes in breastfeeding duration.

DESIGN AND SETTING

Difference-in-difference approach and causal mediation analysis were used to perform secondary statistical analysis of cross-sectional data from Demographic and Health Surveys (DHSs) in 38 LMICs.

PARTICIPANTS

We merged longitudinal data on national maternity leave policies with information on childhood diarrhoea related to 639 153 live births between 1996 and 2014 in 38 LMICs that participated in the DHS at least twice between 1995 and 2015.

PRIMARY OUTCOME MEASURE

Our outcome was whether the child had bloody stools in the 2 weeks prior to the interview. This measure was used as an indicator of severe diarrhoea because the frequency of loose stools in breastfed infants can be difficult to distinguish from pathological diarrhoea based on survey data.

RESULTS

A 1-month increase in the legislated duration of paid maternity leave was associated with a 34% (risk ratio 0.66, 95% CI 0.47 to 0.91) reduction in the prevalence of bloody diarrhoea. Breast feeding for at least 6 months and 12 months mediated 10.6% and 7.4% of this effect, respectively.

CONCLUSION

Extending the duration of paid maternity leave appears to lower diarrhoea prevalence in children under 5 years of age in LMICs. This effect is slightly mediated by changes in breastfeeding duration.

Child wasting and concurrent stunting in low- and middle-income countries

Sustainable Development Goal 2.2-to end malnutrition by 2030-includes the elimination of child wasting, defined as a weight-for-length z-score that is more than two standard deviations below the median of the World Health Organization standards for child growth1. Prevailing methods to measure wasting rely on cross-sectional surveys that cannot measure onset, recovery and persistence-key features that inform preventive interventions and estimates of disease burden. Here we analyse 21 longitudinal cohorts and show that wasting is a highly dynamic process of onset and recovery, with incidence peaking between birth and 3 months. Many more children experience an episode of wasting at some point during their first 24 months than prevalent cases at a single point in time suggest. For example, at the age of 24 months, 5.6% of children were wasted, but by the same age (24 months), 29.2% of children had experienced at least one wasting episode and 10.0% had experienced two or more episodes. Children who were wasted before the age of 6 months had a faster recovery and shorter episodes than did children who were wasted at older ages; however, early wasting increased the risk of later growth faltering, including concurrent wasting and stunting (low length-for-age z-score), and thus increased the risk of mortality. In diverse populations with high seasonal rainfall, the population average weight-for-length z-score varied substantially (more than 0.5 z in some cohorts), with the lowest mean z-scores occurring during the rainiest months; this indicates that seasonally targeted interventions could be considered. Our results show the importance of establishing interventions to prevent wasting from birth to the age of 6 months, probably through improved maternal nutrition, to complement current programmes that focus on children aged 6-59 months.

Lactose versus Lactose Free Regimen in Children with Acute Diarrhea

BACKGROUND: Acute diarrhea (AD) is the most frequent gastroenterological disorder, and the main cause of dehydration in childhood, and it is one of the most important causes of morbidity and mortality in children. AIM: Assessment of lactose-free formula effect in nutritional treatment in formula-fed children with acute diarrhea. PATIENTS AND METHODS: A cross-section interventional study carried out on 60 formula-fed children, under two years, referring with acute diarrhea, 30 children obtain lactose-free formulation and 30 children with no lactose-containing formula. According to the period of diarrheal stop and weight, changes compering two groups. RESULTS: Thirty-two males and 28 females children (7.25 ± 5.1 months) included. Children with lactose-free formula had a significantly slighter dated to diarrhea relief compared with control group children (p < 0.01). No variance between two groups in weight change (6.9 ± 3.03 vs. 7.05 ± 3.07 kg, p = 0.2). (46.6%) of patients on Lactose free formula were discharged on the third post admission day, lactose-free formula has more effective recovery to those on cow milk formula (4.1 ± 1.2 vs. 6 ± 1.3 days, p < 0.01 significant). CONCLUSION: Quick giving of lactose-free formulation to children on formula feeding show rapid relief of acute diarrhea.

Formative Research for the Design of a Baby Water, Sanitation, and Hygiene Mobile Health Program in Bangladesh (CHoBI7 Mobile Health Program)

Poor food hygiene practices, child feces not being disposed of in a latrine, child mouthing of contaminated fomites, and poor hand hygiene of caregivers have been associated with diarrheal diseases, environmental enteropathy, and impaired growth in young children. Mobile health (mHealth) programs present a low-cost approach to delivering water, sanitation, and hygiene (WASH) programs. We conducted a theory-driven and evidence-based approach to formative research and intervention development to design and pilot test a Baby WASH mHealth program targeting food hygiene, child mouthing, and child feces disposal behaviors in urban Dhaka, Bangladesh. Formative research activities included 31 semi-structured interviews, five group discussions, six mHealth workshops, and a three-phase iterative pilot study among 102 households. Findings from semi-structured interviews and group discussions indicate that caregivers of young children have relatively high awareness of the need for safer food hygiene, child mouthing, and child feces disposal practices, but are limited by existing household responsibilities and restricted access to enabling technology that would facilitate practicing recommended behaviors. The piloted Baby WASH mHealth program was well-received by households. This study presents a theory-driven and evidence-based approach for intervention development that can be implemented for the development of future WASH mHealth programs in low-resource settings.

Cesarean delivery and early childhood diseases in Bangladesh: An analysis of Demographic and Health Survey (BDHS) and Multiple Indicator Cluster Survey (MICS)

Introduction

The rate of cesarean delivery (C-section) has been increasing worldwide, including Bangladesh, and it has a negative impact on the mother and child's health. Our aim was to examine the association between C-section and childhood diseases and to identify the key factors associated with childhood diseases.

Methods

We used four nationally representative data sets from multiple indicator cluster survey (MICS, 2012 and 2019) and Bangladesh Demographic and Health Survey (BDHS, 2011and 2014) and analyzed 25,270 mother-child pairs. We used the frequency of common childhood diseases (fever, short or rapid breaths, cough, blood in stools, and diarrhea) as our outcome variable and C-section as exposure variable. We included mother’s age, place of residence, division, mother’s education, wealth index, child age, child sex, and child size at birth as confounding variables. Negative binomial regression model was used to analyze the data.

Results

In the BDHS data, the prevalence of C-section increased from 17.95% in 2011 to 23.33% in 2014. Also, in MICS, the prevalence almost doubled over an eight-year period (17.74% in 2012 to 35.41% in 2019). We did not observe any significant effect of C-section on childhood diseases in both surveys. Only in 2014 BDHS, we found that C-section increases the risk of childhood disease by 5% [Risk Ratio (RR): 1.05, 95% CI: 0.95, 1.17, p = 0.33]. However, the risk of childhood disease differed significantly in all survey years by division, child's age, and child’s size at birth after adjusting for important confounding variables. For example, children living in Chittagong division had a higher risk [(2011 BDHS RR: 1.22, 95% CI: 1.08, 1.38) and (2019 MICS RR: 1.21, 95% CI: 1.08, 1.35)] of having disease compared to Dhaka division. Maternal age, education, and wealth status showed significant differences with the outcome in some survey years.

Conclusion

Our study shows that C-section in Bangladesh continued to increase over time, and we did not find significant association between C-section and early childhood diseases. High C-section rate has a greater impact on maternal and child health as well as the burden on the health care system. We recommend raising public awareness of the negative impact of unnecessary C-section in Bangladesh.

Determinants of Childhood Zoonotic Enteric Infections in a Semirural Community of Quito, Ecuador

Domestic animals in the household environment have the potential to affect a child's carriage of zoonotic enteric pathogens and risk of diarrhea. This study examines the risk factors associated with pediatric diarrhea and carriage of zoonotic enteric pathogens among children living in communities where smallholder livestock production is prevalent. We conducted an observational study of children younger than 5 years that included the analysis of child (n = 306) and animal (n = 480) fecal samples for Campylobacter spp., atypical enteropathogenic Escherichia coli, Shiga toxin-producing E. coli, Salmonella spp., Yersinia spp., Cryptosporidium parvum, and Giardia lamblia. Among these seven pathogens, Giardia was the most commonly identified pathogen among children and animals in the same household, most of which was found in child-dog pairs. Campylobacter spp. was also relatively common within households, particularly among child-chicken and child-guinea pig pairs. We used multivariable Poisson regression models to assess risk factors associated with a child being positive for at least one zoonotic enteric pathogen or having diarrhea during the last week. Children who interacted with domestic animals-a behavior reported by nearly three-quarters of households owning animals-were at an increased risk of colonization with at least one zoonotic enteric pathogen (prevalence ratio [PR] = 1.56, 95% CI: 1.00-2.42). The risk of diarrhea in the last seven days was elevated but not statistically significant (PR = 2.27, CI: 0.91, 5.67). Interventions that aim to reduce pediatric exposures to enteric pathogens will likely need to be incorporated with approaches that remove animal fecal contamination from the domestic environment and encourage behavior change aimed at reducing children's contact with animal feces through diverse exposure pathways.

Factors associated with home visits by volunteer community health workers to implement a home-fortification intervention in Bangladesh: a multilevel analysis

Objective:

BRAC, an international development organization based in Bangladesh, engages community health workers called Shasthya Shebikas (SS) to implement home fortification of foods with micronutrient powders (MNP). We identified factors associated with home visits by SS, at different levels of the BRAC programme-delivery hierarchy, to implement home-fortification interventions.

Design:

We conducted a cross-sectional survey, semi-structured interviews, and collected programme-related data from sub-districts included in the caregiver survey of BRAC’s home-fortification programme and performed multilevel logistic regression modelling to investigate factors associated with home visits by SS.

Settings:

Sixty-eight sub-districts in Bangladesh.

Participants:

Caregivers of children aged 6–59 months (n 1408) and BRAC’s SS (n 201).

Results:

Households with older children (0·55; 0·42, 0·72; P < 0·001) and located >300 m from the SS’s house (0·67; 0·50, 0·89; P = 0·006) were less likely to have been visited by the SS, whereas those with caregivers who had ≥5 years of schooling (1·53; 1·10, 2·12; P = 0·011) were more likely to have been visited by the SS (adjusted OR; 95 % CI). Households in the catchment area of older SS aged >50 years (0·44; 0·21, 0·90; P = 0·025) were less likely to have been visited by the SS, whereas those with SS who received incentives of >800 BDT (3·00; 1·58, 5·58; P = 0·001) were more likely to have been visited by the SS (adjusted OR; 95 % CI).

Conclusions:

The number of home visits is a function of the characteristics of SS, factors that characterize the households they serve and characteristics of their organizational context, particularly to implement home fortification of foods with MNP.

Therapeutic effects of Byrsocarpus coccineus root bark extract on bacterially and chemically induced diarrhea in the Wistar albino rat (Rattus norvegicus domestica)

BACKGROUND

Diarrhea can be caused by pathogenic microorganisms and chemicals. In view of this, Byrsocarpus coccineus Schum and Thonn (Connaraceae) was used to treat diarrhea induced by castor oil or bacteria in Wistar albino rats.

METHODS

Qualitative and quantitative analyses of an aqueous root back extract of B. coccineus were made and the acute toxicity, antidiarrhea properties, and in vitro and in vivo antimicrobial activities of the extract were investigated in rats.

RESULTS

The phytochemical analysis of the root bark extract revealed the presence of flavonoids, alkaloid, saponins, tannins, and phenols. The quantitative analysis showed that saponins formed 10.6% of the extract, tannins 7.6%, flavonoids 6.2%, phenol 5.8% and alkaloids 4.4%. A dose limit of 5000 mg/kg was safe to use in the rats. At a dose of 100 mg/kg, the extract decreased distance travelled by activated charcoal in the gastrointestinal tract, frequency of defecation, and number of unformed faeces caused by castor oil-induced diarrhea, and led to 74.96% inhibition of the diarrhea effects. Escherichia coli and Salmonella pullorum were susceptible to higher concentrations of the extract with a minimum inhibitory concentration of 0.3125 mg/mL. E. coli-infected rats showed depression, weight loss, anorexia, diarrhea, and weakness, which was ameliorated by the extract on day 2 post treatment. Observed congestion, cellular infiltration and necrosis of the liver, intestine and kidney following infection were improved by the extract.

CONCLUSION

B. coccineus extract can be used in the treatment of anaemia, and castor oil- and E. coli-induced diarrhea in rats.

Relationships among Common Illness Symptoms and the Protective Effect of Breastfeeding in Early Childhood in MAL-ED: An Eight-Country Cohort Study

Children in low-income countries experience multiple illness symptoms in early childhood. Breastfeeding is protective against diarrhea and respiratory infections, and these illnesses are thought to be risk factors of one another, but these relationships have not been explored simultaneously. In the eight-site MAL-ED study, 1,731 infants were enrolled near birth and followed for 2 years. We collected symptoms and diet information through twice-weekly household visits. Poisson regression was used to determine if recent illness history was associated with incidence of diarrhea or acute lower respiratory infections (ALRI), accounting for exclusive breastfeeding. Recent diarrhea was associated with higher risk of incident diarrhea after the first 6 months of life (relative risk [RR] 1.10, 95% confidence interval [CI] 1.04, 1.16) and with higher risk of incident ALRI in the 3- to 5-month period (RR 1.23, 95% CI 1.03, 1.47). Fever was a consistent risk factor for both diarrhea and ALRI. Exclusive breastfeeding 0-6 months was protective against diarrhea (0-2 months: RR 0.39, 95% CI 0.32, 0.49; 3-5 months: RR 0.83, 95% CI 0.75, 0.93) and ALRI (3-5 months: RR 0.81, 95% CI 0.68, 0.98). Children with recent illness who were exclusively breastfed were half as likely as those not exclusively breastfed to experience diarrhea in the first 3 months of life. Recent illness was associated with greater risk of new illness, causing illnesses to cluster within children, indicating that specific illness-prevention programs may have benefits for preventing other childhood illnesses. The results also underscore the importance of exclusive breastfeeding in the first 6 months of life for disease prevention.

Mouthing of Soil Contaminated Objects is Associated with Environmental Enteropathy in Young Children

OBJECTIVE

To characterise childhood mouthing behaviours and to investigate the association between object-to-mouth and food-to-mouth contacts, diarrhoea prevalence and environmental enteropathy.

METHODS

A prospective cohort study was conducted of 216 children ≤30 months of age in rural Bangladesh. Mouthing contacts with soil and food and objects with visible soil were assessed by 5-h structured observation. Stool was analysed for four faecal markers of intestinal inflammation: alpha-1-antitrypsin, myeloperoxidase, neopterin and calprotectin.

RESULTS

Overall 82% of children were observed mouthing soil, objects with visible soil, or food with visible soil during the structured observation period. Sixty two percent of children were observed mouthing objects with visible soil, 63% were observed mouthing food with visible soil, and 18% were observed mouthing soil only. Children observed mouthing objects with visible soil had significantly elevated faecal calprotectin concentrations (206.81 μg/g, 95% confidence interval [CI]: 6.27, 407.36). There was also a marginally significant association between Escherichia coli counts in soil from a child's play space and the prevalence rate of diarrhoea (diarrhoea prevalence ratio: 2.03, 95% CI 0.97, 4.25).

CONCLUSION

These findings provide further evidence to support the hypothesis that childhood mouthing behaviour in environments with faecal contamination can lead to environmental enteropathy in susceptible paediatric populations. Furthermore, these findings suggest that young children mouthing objects with soil, which occurred more frequently than soil directly (60% vs. 18%), was an important exposure route to faecal pathogens and a risk factor for environmental enteropathy.

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Zusammenfassung. Die häufigsten Gründe, weshalb ein Kind in der Praxis oder im Spital vorgestellt wird, sind Dehydratation und Trink-/Essensverweigerung aufgrund einer akuten Gastroenteritis (AGE). Die häufigste Ursache einer AGE ist das Rotavirus, gefolgt von Norovirus und seltenen bakteriellen Erkrankungen. Eine Erregerdiagnostik ist dabei nur selten nötig. Der Dehydratationsgrad wird vornehmlich klinisch anhand eines Dehydratations-Scores gestellt. Ziel der Dehydratationstherapie sind die rasche Rehydrierung und Wiederaufnahme von Flüssigkeit und Nahrung durch das Kind. Eine Rehydratationstherapie (RT) sollte wenn immer möglich per os oder per Magensonde stattfinden und nur in schweren Fällen intravenös. Bei einem prolongierten Verlauf sind weitere Abklärungen beim gastroenterologischen Spezialisten empfehlenswert.

Risk factors for diarrhea in children under five years of age residing in peri-urban communities in Cochabamba, Bolivia

This study examined the relationship between childhood diarrhea prevalence and caregiver knowledge of the causes and prevention of diarrhea in a prospective cohort of 952 children < 5 years of age in Cochabamba, Bolivia. The survey of caregiver knowledge found that more than 80% of caregivers were unaware that hand washing with soap could prevent childhood diarrhea. Furthermore, when asked how to keep food safe for children to eat only 17% of caregivers reported hand washing before cooking and feeding a child. Lack of caregiver awareness of the importance of practices related to hygiene and sanitation for diarrhea prevention were significant risk factors for diarrheal disease in this cohort. The knowledge findings from this study suggest that health promotion in these communities should put further emphasis on increasing knowledge of how water treatment, hand washing with soap, proper disposal of child feces, and food preparation relate to childhood diarrhea prevention.

European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014

OBJECTIVES

These guidelines update and extend evidence-based indications for the management of children with acute gastroenteritis in Europe.

METHODS

The guideline development group formulated questions, identified data, and formulated recommendations. The latter were graded with the Muir Gray system and, in parallel, with the Grading of Recommendations, Assessment, Development and Evaluations system.

RESULTS

Gastroenteritis severity is linked to etiology, and rotavirus is the most severe infectious agent and is frequently associated with dehydration. Dehydration reflects severity and should be monitored by established score systems. Investigations are generally not needed. Oral rehydration with hypoosmolar solution is the major treatment and should start as soon as possible. Breast-feeding should not be interrupted. Regular feeding should continue with no dietary changes including milk. Data suggest that in the hospital setting, in non-breast-fed infants and young children, lactose-free feeds can be considered in the management of gastroenteritis. Active therapy may reduce the duration and severity of diarrhea. Effective interventions include administration of specific probiotics such as Lactobacillus GG or Saccharomyces boulardii, diosmectite or racecadotril. Anti-infectious drugs should be given in exceptional cases. Ondansetron is effective against vomiting, but its routine use requires safety clearance given the warning about severe cardiac effects. Hospitalization should generally be reserved for children requiring enteral/parenteral rehydration; most cases may be managed in an outpatients setting. Enteral rehydration is superior to intravenous rehydration. Ultrarapid schemes of intravenous rehydration are not superior to standard schemes and may be associated with higher readmission rates.

CONCLUSIONS

Acute gastroenteritis is best managed using a few simple, well-defined medical interventions.

Persistent gut microbiota immaturity in malnourished Bangladeshi children

Therapeutic food interventions have reduced mortality in children with severe acute malnutrition (SAM), but incomplete restoration of healthy growth remains a major problem. The relationships between the type of nutritional intervention, the gut microbiota, and therapeutic responses are unclear. In the current study, bacterial species whose proportional representation define a healthy gut microbiota as it assembles during the first two postnatal years were identified by applying a machine-learning-based approach to 16S ribosomal RNA data sets generated from monthly faecal samples obtained from birth onwards in a cohort of children living in an urban slum of Dhaka, Bangladesh, who exhibited consistently healthy growth. These age-discriminatory bacterial species were incorporated into a model that computes a 'relative microbiota maturity index' and 'microbiota-for-age Z-score' that compare postnatal assembly (defined here as maturation) of a child's faecal microbiota relative to healthy children of similar chronologic age. The model was applied to twins and triplets (to test for associations of these indices with genetic and environmental factors, including diarrhoea), children with SAM enrolled in a randomized trial of two food interventions, and children with moderate acute malnutrition. Our results indicate that SAM is associated with significant relative microbiota immaturity that is only partially ameliorated following two widely used nutritional interventions. Immaturity is also evident in less severe forms of malnutrition and correlates with anthropometric measurements. Microbiota maturity indices provide a microbial measure of human postnatal development, a way of classifying malnourished states, and a parameter for judging therapeutic efficacy. More prolonged interventions with existing or new therapeutic foods and/or addition of gut microbes may be needed to achieve enduring repair of gut microbiota immaturity in childhood malnutrition and improve clinical outcomes.

Catch-up growth occurs after diarrhea in early childhood

Diarrhea and linear growth faltering continue to burden low-income countries and are among the most important contributors to poor health during early childhood. Diarrhea is thought to adversely affect linear growth, but catch-up growth can occur if no additional insults are experienced. We sought to characterize catch-up growth in relation to diarrhea burden in a multisite dataset of 1007 children. Using longitudinal anthropometry and diarrheal surveillance data from 7 cohort studies in 4 countries, we examined the relation between diarrhea prevalence and growth in 3- to 6-mo periods using linear mixed-effect models. Growth during each period was calculated as a function of age using linear splines. We incorporated the longitudinal prevalence of diarrhea in both current and previous periods into the model. Diarrhea during the current period was associated with slower linear and ponderal growth. Faster (catch-up) growth in length was observed in children with no diarrhea in age groups immediately after an age group in which diarrhea was experienced [age group >6-12 mo: 0.03 mm/mo for each percentage diarrhea prevalence in the previous period (95% CI: 0.007, 0.06) relative to 11.3 mm/mo mean growth rate; age group >12-18 mo: 0.04 mm/mo (95% CI: 0.02, 0.06) relative to 8.9 mm/mo mean growth rate; age group >18-24 mo: 0.04 mm/mo (95% CI: 0.003, 0.09) relative to 7.9 mm/mo mean growth rate]. The associations were stronger in boys than in girls when separate models were run. Similar results were observed when weight was the outcome variable. When diarrheal episodes are followed by diarrhea-free periods in the first 2 y of life, catch-up growth is observed that may allow children to regain their original trajectories. The finding of a greater effect of diarrhea on linear growth in boys than in girls was unexpected and requires additional study. Diarrhea burdens are high throughout the first 2 y of life in these study sites, therefore reducing the likelihood of catch-up growth. Extending diarrhea-free periods may increase the likelihood of catch-up growth and decrease the prevalence of stunting.

Diarrhea in early childhood: short-term association with weight and long-term association with length

The short-term association between diarrhea and weight is well-accepted, but the long-term association between diarrhea and growth is less clear. Using data from 7 cohort studies (Peru, 1985-1987; Peru, 1989-1991; Peru, 1995-1998; Brazil, 1989-1998; Guinea-Bissau, 1987-1990; Guinea-Bissau, 1996-1997; and Bangladesh, 1993-1996), we evaluated the lagged relationship between diarrhea and growth in the first 2 years of life. Our analysis included 1,007 children with 597,638 child-days of diarrhea surveillance and 15,629 anthropometric measurements. We calculated the associations between varying diarrhea burdens during lagged 30-day periods and length at 24 months of age. The cumulative association between the average diarrhea burden and length at age 24 months was -0.38 cm (95% confidence interval: -0.59, -0.17). Diarrhea during the 30 days prior to anthropometric measurement was consistently associated with lower weight at most ages, but there was little indication of a short-term association with length. Diarrhea was associated with a small but measurable decrease in linear growth over the long term. These findings support a focus on prevention of diarrhea as part of an overall public health strategy for improving child health and nutrition; however, more research is needed to explore catch-up growth and potential confounders.

Prevalence, seasonality and severity of disease caused by pathogenic Escherichia coli in children with diarrhoea in Bolivia

The prevalence of infection caused by different categories of diarrhoeagenic E. coli (DEC) strains, including enteroaggregative (EAEC), enteropathogenic (EPEC), enterotoxigenic (ETEC), enteroinvasive (EIEC) and enterohaemorrhagic (EHEC) E. coli, in children who suffered from diarrhoea (n = 3943) or did not have diarrhoea (n = 1026) were analysed in two areas in Bolivia over a period of 4 years. We also analysed the seasonality of DEC infections and severity of diarrhoea in children with DEC infection and compared antibiotic resistance in DEC strains isolated from children with and without diarrhoea. Stool samples were analysed for the presence of DEC by culturing followed by PCR. The most prevalent DEC categories in samples from the children were: EAEC (11.2 %); ETEC (6.6 %); EPEC (5.8 %); and EIEC and EHEC (<1 %). DEC strains were isolated significantly more often from diarrhoea cases (21.6 %) than from controls (17.6 %; P = 0.002). The number of children with diarrhoea associated with EAEC, EPEC and ETEC infections peaked in the Bolivian winter (April-September), although the proportion of DEC-positive stool samples was higher during the warm rainy season (October-March). High levels of antibiotic resistance were detected among the DEC strains. In particular, resistance to tetracycline and sulfamethoxazole-trimethoprim was significantly higher in strains isolated from individuals with diarrhoea than in samples from controls. The severity of disease in children infected with EAEC, EPEC and ETEC varied from mild to severe diarrhoea, although disease severity did not differ significantly between the different DEC categories. ETEC, EPEC and EAEC are commonly found in Bolivia and may cause severe disease in children.

Health care-seeking behavior for childhood diarrhea in Mirzapur, rural Bangladesh

We evaluated patterns of health care use for diarrhea among children 0–59 months of age residing in Mirzapur, Bangladesh, using a baseline survey conducted during May–June 2007 to inform the design of a planned diarrheal etiology case/control study. Caretakers of 7.4% of 1,128 children reported a diarrheal illness in the preceding 14 days; among 95 children with diarrhea, 24.2% had blood in the stool, 12.2% received oral rehydration solution, 27.6% received homemade fluids, and none received zinc at home. Caretakers of 87.9% sought care outside the home; 49.9% from a pharmacy, and 22.1% from a hospital or health center. The primary reasons for not seeking care were maternal perception that the illness was not serious enough (74.0%) and the high cost of treatment (21.9%). To improve management of childhood diarrhea in Mirzapur, Bangladesh, it will be important to address knowledge gaps in caretakers' assessment of illness severity, appropriate home management, and when to seek care in the formal sector. In addition, consideration should be given to inclusion of the diverse care-giving settings in clinical training activities for diarrheal disease management.

Global burden of childhood pneumonia and diarrhoea

Diarrhoea and pneumonia are the leading infectious causes of childhood morbidity and mortality. We comprehensively reviewed the epidemiology of childhood diarrhoea and pneumonia in 2010-11 to inform the planning of integrated control programmes for both illnesses. We estimated that, in 2010, there were 1·731 billion episodes of diarrhoea (36 million of which progressed to severe episodes) and 120 million episodes of pneumonia (14 million of which progressed to severe episodes) in children younger than 5 years. We estimated that, in 2011, 700,000 episodes of diarrhoea and 1·3 million of pneumonia led to death. A high proportion of deaths occurs in the first 2 years of life in both diseases--72% for diarrhoea and 81% for pneumonia. The epidemiology of childhood diarrhoea and that of pneumonia overlap, which might be partly because of shared risk factors, such as undernutrition, suboptimum breastfeeding, and zinc deficiency. Rotavirus is the most common cause of vaccine-preventable severe diarrhoea (associated with 28% of cases), and Streptococcus pneumoniae (18·3%) of vaccine-preventable severe pneumonia. Morbidity and mortality from childhood pneumonia and diarrhoea are falling, but action is needed globally and at country level to accelerate the reduction.

Epidemiological features and risk factors of Salmonella gastroenteritis in children resident in Ho Chi Minh City, Vietnam

Non-typhoidal Salmonella are an important but poorly characterized cause of paediatric diarrhoea in developing countries. We conducted a hospital-based case-control study in children aged <5 years in Ho Chi Minh City to define the epidemiology and examine risk factors associated with Salmonella diarrhoeal infections. From 1419 diarrhoea cases and 571 controls enrolled between 2009 and 2010, 77 (5·4%) diarrhoea cases were stool culture-positive for non-typhoidal Salmonella. Salmonella patients were more likely to be younger than controls (median age 10 and 12 months, respectively) [odds ratio (OR) 0·97; 95% confidence interval (CI) 0·94–0·99], to report a recent diarrhoeal contact (8·1% cases, 1·8% controls; OR 5·98, 95% CI 1·8–20·4) and to live in a household with >2 children (cases 20·8%, controls 10·2%; OR 2·32, 95% CI 1·2–4·7). Our findings indicate that Salmonella are an important cause of paediatric gastroenteritis in this setting and we suggest that transmission may occur through direct human contact in the home.

Wasting is associated with stunting in early childhood

The longitudinal relationship between stunting and wasting in children is poorly characterized. Instances of wasting or poor weight gain may precede linear growth retardation. We analyzed longitudinal anthropometric data for 1599 children from 8 cohort studies to determine the effect of wasting [weight-for-length Z-score (WLZ) < -2] and variability in WLZ in the first 17 mo on length-for-age Z-score (LAZ) at 18-24 mo of age. In addition, we considered the effects of change in WLZ during the previous 6-mo period on length at 18 and 24 mo. Wasting at 6-11 or 12-17 mo was associated with decreased LAZ; however, children who experienced wasting only at 0-5 mo did not suffer any long-term growth deficits compared with children with no wasting during any period. Children with greater WLZ variability (≥0.5 SD) in the first 17 mo of life were shorter [LAZ = -0.51 SD (95% CI: -0.67, -0.36 SD)] at 18-24 mo of age than children with WLZ variability <0.5. Change in WLZ in the previous 6-mo period was directly associated with greater attained length at 18 mo [0.33 cm (95% CI: 0.11, 0.54 cm)] and 24 mo [0.72 cm (95% CI: 0.52, 0.92 cm)]. Children with wasting, highly variable WLZ, or negative changes in WLZ are at a higher risk for linear growth retardation, although instances of wasting may not be the primary cause of stunting in developing countries.

Systematic review of diarrhea duration and severity in children and adults in low- and middle-income countries

Background

Diarrhea is a leading cause of morbidity and mortality globally; yet the overall burden of diarrhea in terms of duration and severity has not been quantified. As improvements in treatment lead to decreases in diarrhea mortality, it is important to understand the substantial impact of diarrhea morbidity on disability among children and adults worldwide.

Methods

We conducted a systematic review to generate estimates of duration and severity outcomes for individuals 0-59 mos, 5-15 yrs, and ≥ 16 yrs, and for 3 severity indexes: mild, moderate, and severe.

Results

We estimate that among children under-five, 64.8% of diarrheal episodes are mild, 34.7% are moderate, and 0.5% are severe. On average, mild episodes last 4.3 days, and severe episodes last 8.4 days and cause dehydration in 84.6% of cases. We estimate that among older children and adults, 95% of episodes are mild; 4.95% are moderate; and 0.05% are severe. Among individuals ≥ 16 yrs, severe episodes typically last 2.6 days and cause dehydration in 92.8% of cases.

Conclusions

Moderate and severe episodes constitute a substantial portion of the total envelope of diarrhea among children under-five (35.2%; about 588 million episodes). Among older children and adults, moderate and severe episodes account for a much smaller proportion of the total envelope of diarrhea (5%), but the absolute number of such episodes is noteworthy (about 21.5 million episodes among individuals ≥ 16 yrs). Hence, the global burden of diarrhea consists of significant morbidity, extending beyond episodes progressing to death.

Vulnerability of newborns to environmental factors: findings from community based surveillance data in Bangladesh

Infection is the major cause of neonatal deaths. Home born newborns in rural Bangladeshi communities are exposed to environmental factors increasing their vulnerability to a number of disease agents that may compromise their health. The current analysis was conducted to assess the association of very severe disease (VSD) in newborns in rural communities with temperature, rainfall, and humidity. A total of 12,836 newborns from rural Sylhet and Mirzapur communities were assessed by trained community health workers using a sign based algorithm. Records of temperature, humidity, and rainfall were collected from the nearest meteorological stations. Associations between VSD and environmental factors were estimated. Incidence of VSD was found to be associated with higher temperatures (odds ratios: 1.14, 95% CI: 1.08 to 1.21 in Sylhet and 1.06, 95% CI: 1.04 to 1.07 in Mirzapur) and heat humidity index (odds ratios: 1.06, 95% CI: 1.04 to 1.08 in Sylhet and, 1.03, 95% CI: 1.01 to 1.04 in Mirzapur). Four months (June–September) in Sylhet, and six months in Mirzapur (April–September) had higher odds ratios of incidence of VSD as compared to the remainder of the year (odds ratios: 1.72, 95% CI: 1.32 to 2.23 in Sylhet and, 1.62, 95% CI: 1.33 to 1.96 in Mirzapur). Prevention of VSD in neonates can be enhanced if these interactions are considered in health intervention strategies.

Iron-containing micronutrient powder provided to children with moderate-to-severe malnutrition increases hemoglobin concentrations but not the risk of infectious morbidity: a randomized, double-blind, placebo-controlled, noninferiority safety trial

BACKGROUND

A link between the provision of iron and infectious morbidity has been suggested, particularly in children with malnutrition. Two meta-analyses concluded that iron is not harmful, but malnourished children were underrepresented in most available studies.

OBJECTIVE

This study evaluated the effect of iron-containing micronutrient powder (iron MNP) on infectious morbidities when provided to children with moderate-to-severe malnutrition and anemia.

DESIGN

A randomized, double-blind, placebo-controlled, noninferiority safety trial using a 2-mo course of daily iron MNP or placebo powder (PP) was conducted in 268 Bangladeshi children aged 12-24 mo with moderate-to-severe malnutrition (weight-for-age z score ≤ -2) and a hemoglobin concentration between 70 and 110 g/L. The primary endpoint was a composite of diarrhea, dysentery, and lower respiratory tract infection episodes (DDL) recorded through home visits every 2 d during the intervention and then weekly for 4 mo. The noninferiority margin was 1.2. Secondary endpoints included hemoglobin and anthropometric changes at 2 and 6 mo. All deaths and hospitalizations were documented. To capture seasonal variation, the study was repeated in the winter and summer with 2 distinct groups. An intention-to-treat analysis of recurrent events was performed by using the univariate Anderson-Gill model.

RESULTS

The baseline characteristics of the subjects were similar. Analysis of phase-aggregated DDL data showed that iron MNP was not inferior to PP (relative risk: 0.81; 95% CI: 0.62, 1.04) and improved hemoglobin concentrations (P < 0.0001). We recorded no deaths, and hospitalizations were rare.

CONCLUSION

Iron MNP is safe and efficacious when provided to children aged 12-24 mo with moderate-to-severe malnutrition and anemia. This trial is registered at clinicaltrials.gov as NCT00530374.

Arsenic exposure in pregnancy increases the risk of lower respiratory tract infection and diarrhea during infancy in Bangladesh

BACKGROUND

Previous studies have reported associations between prenatal arsenic exposure and increased risk of infant mortality. An increase in infectious diseases has been proposed as the underlying cause of these associations, but there is no epidemiologic research to support the hypothesis.

OBJECTIVE

We evaluated the association between arsenic exposure in pregnancy and morbidity during infancy.

METHODS

This prospective population-based cohort study included 1,552 live-born infants of women enrolled during 2002-2004 in Matlab, Bangladesh. Arsenic exposure was assessed by the concentrations of metabolites of inorganic arsenic in maternal urine samples collected at gestational weeks 8 and 30. Information on symptoms of lower respiratory tract infection (LRTI) and diarrhea in infants was collected by 7-day recalls at monthly home visits.

RESULTS

In total, 115,850 person-days of observation were contributed by the infants during a 12-month follow-up period. The estimated risk of LRTI and severe LRTI increased by 69% [adjusted relative risk (RR) = 1.69; 95% confidence interval (CI), 1.36-2.09)] and 54% (RR = 1.54; 95% CI, 1.21-1.97), respectively, for infants of mothers with urinary arsenic concentrations in the highest quintile (average of arsenic concentrations measured in early and late gestation, 262-977 µg/L) relative to those with exposure in the lowest quintile (< 39 µg/L). The corresponding figure for diarrhea was 20% (RR = 1.20; 95% CI, 1.01-1.43).

CONCLUSIONS

Arsenic exposure during pregnancy was associated with increased morbidity in infectious diseases during infancy. Taken together with the previous evidence of adverse effects on health, the findings strongly emphasize the need to reduce arsenic exposure via drinking water.

The epidemiology of hospitalization with diarrhea in rural Kenya: the utility of existing health facility data in developing countries

OBJECTIVES

In developing countries where prospective surveillance is resource-intensive, existing hospital data can define incidence, mortality, and risk factors that can help target interventions and track trends in disease burden.

METHODS

We reviewed hospitalizations from 2001 to 2003 at all inpatient facilities in Bondo District, Kenya.

RESULTS

Diarrhea was responsible for 11.2% (n=2158) of hospitalizations. The annual incidence was 550 and 216 per 100,000 persons aged <5 and > or =5 years, respectively. The incidence was highest in infants (1138 per 100,000 persons), decreased in older children, peaked again among 20-29-year-olds (341 per 100,000), and declined among those > or =65 years (157 per 100,000). Female adults had higher incidence than males (rate ratio=1.84, 95% CI 1.61-2.10). Incidence decreased with distance from the district referral hospital (4.5% per kilometer, p<0.0001) and from the nearest inpatient facility (6.6% per kilometer, p=0.012). Case-fatality was high (8.0%), and was higher among adults than young children. Co-diagnosis with malaria, pneumonia, HIV, and tuberculosis was common. Peak diarrhea incidence fell one to two months after heavy rains.

CONCLUSIONS

The trends revealed here provide useful data for public health priority setting and planning, including preventative interventions. The utility of such data justifies renewed efforts to establish and strengthen health management information systems in developing countries.

Water privatization, water source, and pediatric diarrhea in Bolivia: epidemiologic analysis of a social experiment

Water and sanitation services are fundamental to the prevention of pediatric diarrhea. To enhance both access to water and investment, some argue for the privatization of municipal water networks. Water networks in multiple Bolivian cities were privatized in the 1990s, but contracts ended following popular protests citing poor access. A population-based retrospective cohort study was conducted in two Bolivian cities. Data were collected on family water utilization and sanitation practices and on the prevalence of diarrhea among 596 children. Drinking from an outdoor water source (OR, 2.08; 95%CI, 1.25-3.44) and shorter in-home water boiling times (OR, 1.99; 95%CI, 1.19-3.34) were associated with prevalence of diarrhea. Increased prevalence was also observed for children from families using private versus public water services, using off-network water from cistern trucks, or not treating their water in-home. Results suggest that water source, water provider, and in-home water treatment are important predictors of pediatric diarrhea.

Association between infant feeding patterns and diarrhoeal and respiratory illness: a cohort study in Chittagong, Bangladesh

Background

In developing countries, infectious diseases such as diarrhoea and acute respiratory infections are the main cause of mortality and morbidity in infants aged less than one year. The importance of exclusive breastfeeding in the prevention of infectious diseases during infancy is well known. Although breastfeeding is almost universal in Bangladesh, the rates of exclusive breastfeeding remain low. This cohort study was designed to compare the prevalence of diarrhoea and acute respiratory infection (ARI) in infants according to their breastfeeding status in a prospective cohort of infants from birth to six months of age.

Methods

A total of 351 pregnant women were recruited in the Anowara subdistrict of Chittagong. Breastfeeding practices and the 7-day prevalence of diarrhoea and ARI were recorded at monthly home visits. Prevalences were compared using chi-squared tests and logistic regression.

Results

A total of 272 mother-infant pairs completed the study to six months. Infants who were exclusively breastfed for six months had a significantly lower 7-day prevalence of diarrhoea [AOR for lack of EBF = 2.50 (95%CI 1.10, 5.69), p = 0.03] and a significantly lower 7-day prevalence of ARI [AOR for lack of EBF = 2.31 (95%CI 1.33, 4.00), p < 0.01] than infants who were not exclusively breastfed. However, when the association between patterns of infant feeding (exclusive, predominant and partial breastfeeding) and illness was investigated in more detail, there was no significant difference in the prevalence of diarrhoea between exclusively [6.6% (95% CI 2.8, 10.4)] and predominantly breastfed infants [3.7% (95% CI 0.09, 18.3), (p = 0.56)]. Partially breastfed infants had a higher prevalence of diarrhoea than the others [19.2% (95% CI 10.4, 27.9), (p = 0.01)]. Similarly, although there was a large difference in prevalence in acute respiratory illness between exclusively [54.2% (95%CI 46.6, 61.8)] and predominantly breastfed infants [70.4% (95%CI 53.2, 87.6)] there was no significant difference in the prevalence (p = 0.17).

Conclusion

The findings suggest that exclusive or predominant breastfeeding can reduce rates of morbidity significantly in this region of rural Bangladesh.

Intimate partner violence and infant morbidity: evidence of an association from a population-based study in eastern Uganda in 2003

Background

Although recent studies suggest that there is an association between intimate partner violence and child mortality, the underlying mechanisms are still unknown. It is against this background that as a secondary objective, we set out to explore whether an association exists between intimate partner violence and illness in infants.

Methods

We conducted a population based household survey in Mbale, eastern Uganda in 2003. Participants were 457 women (with 457 infants) who consented to participate in the study. We measured socio-demographics of women and occurrence of intimate partner violence. We measured socio-demographics, immunization, nutritional status, and illness in the previous two weeks of the children.

Results

The mean age of the women was 25 years (SD 5.7) while the mean age of the infants was 6 months (SD 3.5). The prevalence of lifetime intimate partner violence was 54% (95% CI 48%–60%). During the previous two weeks, 50% (95% CI 50%–54%) of the children had illness (fever, diarrhoea, cough and fast breathing). Lifetime intimate partner violence was associated with infant illness (OR 1.8, 95% CI 1.2–2.8) and diarrhoea (OR 2.0, 95% CI 1.2–3.4).

Conclusion

Our findings suggest that infant illnesses (fever, diarrhoea, cough and fast breathing) are associated with intimate partner violence, and provide insights into previous reports that have shown an association between intimate partner violence and child mortality, suggesting possible underlying mechanisms. Our findings also highlight the importance of intimate partner violence on the health of children, and the need for further research in this area.