Malnutrition as an enteric infectious disease with long-term effects on child development

Transgression of planetary boundaries and the effects on child health through an infectious diseases lens

PURPOSE OF REVIEW

Life on earth, as we know it, is changing. The likelihood of more frequent pandemics and disease outbreaks is something that current global healthcare infrastructure is ill equipped to navigate. Human activity is forcing our planet into a new geologic epoch, the Anthropocene, which is typified by increased uncertainty resulting from human disruption of earth's life-giving ecosystems. Plagues and pandemics have always been unfortunate partners to periods of disruption, as they will be again if the frequency and severity of climate and conflict-mediated disasters increase in coming years. If we continue to exceed and degrade the planetary boundaries that protect human health, our children and their children will reap the consequences.

RECENT FINDINGS

Scientists have defined nine 'safe operating' planetary boundaries for life in all its glorious diversity to thrive on planet earth. Recent evidence suggests that six of these nine boundaries have already been transgressed, but the potential implications for these transgressions upon child health is not well articulated. We highlight how contravention of these boundaries will impact infectious disease risk and humans' ability to survive and thrive. We reflect specifically on how paediatricians are called upon to speak up for the most vulnerable members of our species, young children and as yet unborn future generations.

SUMMARY

Post COVID-19 initiatives to improve pandemic preparedness and response are certainly warranted, but pandemic prevention should include committed efforts not to exceed safe planetary boundaries. Willingly exceeding these boundaries has deep moral consequences that are poorly articulated by current ethical frameworks. Paediatricians are best placed to develop and champion the neglected 'third dimension' of medical ethics, recognizing the moral imperative to protect the long-term best interests of children and future generations.

The global burden of childhood diarrheal diseases attributable to suboptimal breastfeeding from 1990 to 2021: an exploratory analysis of estimates from the global burden of disease study

BACKGROUND

Understanding the spatial and temporal patterns of the disease burden of childhood diarrhea attributable to suboptimal breastfeeding (including non-exclusive and discontinued breastfeeding) is crucial for global health policy and intervention strategies. This study aimed to comprehensively assess the global, regional, and national burden of childhood diarrheal diseases attributable to suboptimal breastfeeding in 204 countries and territories from 1990 to 2021.

METHODS

This study utilized data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 to estimate deaths, disability-adjusted life years (DALYs), age-standardized mortality rate (ASMR), and age-standardized DALY rate (ASDR) of childhood diarrheal diseases attributable to suboptimal breastfeeding. Suboptimal breastfeeding was assessed as a combination of non-exclusive breastfeeding and discontinued breastfeeding. And the average annual percentage change (AAPC) from 1990 to 2021 was calculated to determine long-term trends. Additionally, frontier analyses were conducted to evaluate the efficiency of different countries in reducing the disease burden relative to their socio-demographic index (SDI) levels.

RESULTS

By 2021, the global number of deaths and DALYs attributable to childhood diarrheal diseases due to suboptimal breastfeeding was 63,133 and 573,430, respectively. Between 1990 and 2021, the number of deaths and DALYs, as well as ASMR (AAPC: -5.40) and ASDR (AAPC: -5.38), declined by approximately 80%. However, significant disparities persist across regions. Low-SDI regions, particularly in Western Sub-Saharan Africa, continued to bear the highest disease burden. At the countries or territories level, Nigeria, India, and Chad recorded the highest number of deaths and DALYs, while Chad, South Sudan, and Lesotho exhibited the highest ASMR and ASDR values. Similar patterns were observed for non-exclusive and discontinued breastfeeding, with the greatest burden concentrated in resource-limited settings.

CONCLUSION

While the global burden of childhood diarrheal diseases attributable to suboptimal breastfeeding has significantly declined over the past three decades, the disease burden remains disproportionately high in less developed regions. These findings underscore the urgent need for targeted public health policies and interventions to promote exclusive and continued breastfeeding, especially in high-burden regions, to further reduce preventable childhood morbidity and mortality.

The ABCDs of Nutritional Assessment in Infectious Diseases Research

Malnutrition is the most common acquired cause of immunodeficiency worldwide. Nutritional deficiencies can blunt both the innate and adaptive immune response to pathogens. Furthermore, malnutrition is both a cause and consequence of infectious diseases. The bidirectional relationship between infectious diseases and undernutrition, as well as the inflammatory milieu of infectious diseases, can complicate nutritional assessment. This article aims to provide clinicians and researchers with an overview of commonly used tools to assess nutritional status, with a particular emphasis on their use in the context of infectious diseases. These tools include anthropometric, biochemical, clinical/physical, and dietary assessments to screen and evaluate undernutrition, diet quality, and food insecurity effectively.

Rapid and sensitive whole cell E. coli detection using deep eutectic solvents/graphene oxide/gold nanoparticles field-effect transistor

Every year, millions of people suffer from gastrointestinal inflammation caused by E. coli. The increase of antibiotic-resistant strains and similar inflammatory and infectious syndromes symptoms have made rapid and sensitive diagnosis of this pathogen challenging. This study developed a Field-Effect Transistor based on deep eutectic solvents, graphene oxide, and gold nanoparticles (DES/GO/AuNPs-FET) to detect E. coli. Comparing the output current showed DES, which was a mixture of ethylene glycol and choline chloride, with ionic behavior, in addition to improving the electrical properties of GO, also led to the formation of AuNPs by self-assembly, which significantly increased the sensor's sensing performance. E. coli lipopolysaccharide aptamer immobilized on DES/GO/AuNPs-FET; capturing E. coli and changing the conformation caused changes in the charge carrier flow in the FET. This nanobiosensor detected E. coli in a completely selective manner in complex matrices like human blood serum. The excellent sensing performance of this nanobiosensor compared to other biosensors with a low detection limit (LOD = 3 CFU/ml), label-free, fast, and real-time detection showed that DES/GO/AuNPs-FET could be a reliable alternative to existing detection methods.

Water, sanitation, handwashing, and nutritional interventions can reduce child antibiotic use: evidence from Bangladesh and Kenya

Antibiotics can trigger antimicrobial resistance and microbiome alterations. Reducing pathogen exposure and undernutrition can reduce infections and antibiotic use. We assess effects of water, sanitation, handwashing (WSH) and nutrition interventions on caregiver-reported antibiotic use in Bangladesh and Kenya, longitudinally measured at three timepoints among birth cohorts (ages 3-28 months) in a cluster-randomized trial. Over 50% of children used antibiotics at least once in the 90 days preceding data collection. In Bangladesh, the prevalence of antibiotic use was 10-14% lower in groups receiving WSH (prevalence ratio [PR] = 0.90 (0.82-0.99)), nutrition (PR = 0.86 (0.78-0.94)), and nutrition+WSH (PR = 0.86 (0.79-0.93)) interventions. The prevalence of using antibiotics multiple times was 26-35% lower in intervention arms. Reductions were largest when the birth cohort was younger. In Kenya, interventions did not affect antibiotic use. In this work, we show that improving WSH and nutrition can reduce antibiotic use. Studies should assess whether such reductions translate to reduced antimicrobial resistance.

Apolipoprotein E4 and Alzheimer's disease causality under adverse environments and potential intervention by senolytic nutrients

Apolipoprotein E (apoE) has a pivotal role in Alzheimer's Disease (AD) pathophysiology. APOE4 has been recognized as a risk factor for developing late-onset AD. Recently, APOE4 homozygosity was regarded as a new familial genetic trait of AD. In this opinion paper, we summarized the potential pleiotropic antagonism role of APOE4 in children living under early life adversity and afflicted with enteric infection/malnutrition-related pathogenic exposome. APOE4 was found to be neuroprotective early in life despite its increasing risk for AD with aging. We call for awareness of the potential burden this can bring to the public health system when APOE4 carriers, raised under adverse environmental conditions in early life and then aging with unhealthy lifestyles in later life may be at special risk for cognitive impairments and acquired AD. We postulate the importance of anti-senescence therapies to protect these individuals and remediate aging-related chronic illnesses.

Exploring the Relationship of Paediatric Nutritional Status with Diarrhoeal Disease in Children Below Two Years of Age

Background and objective: Paediatric malnutrition has a synergistic relationship with diarrhoea. In children under two years of age, diarrhoea occurs in more than half of malnutrition cases and is associated with increased duration of illness, increased length of hospital stays, increased morbidity, and mortality. A well-established relationship exists between diarrhoeal and various standalone forms of malnutrition, but their association with coexisting forms of malnutrition (CFM) has not yet been investigated. Thus, this study assessed the association of CFM with diarrhoea among Pakistani children using datasets retrieved from Demographic Health & Survey and UNICEF. Study design: A pooled analysis of datasets of Pakistan Demographic & Health Surveys (PDHS) and Multiple Indicator Cluster Surveys (MICS) from the year 2010 to 2018 was conducted. Methods: Data of 70,723 children aged below two years were analysed after excluding those with incomplete anthropometry and outliers. Findings: Of the total study population, this study reported the presence of either diarrhoea or malnutrition or both in over half of Pakistani children aged between 0 and 23.9 months. Both standalone forms of undernutrition and coexisting forms of undernutrition were significantly associated with increased odds of diarrhoea by 1.07 (1.02 to 1.12) and 1.21 (1.16 to 1.27) times. The practice of breastfeeding, secondary/higher level of maternal education, and improvement in socioeconomic status reduced the risk of diarrhoea, while the children aged between 6 and 23.9 months residing in urban areas showed a high risk of diarrhoea. Conclusions: The presence of any type of undernutrition, i.e., standalone and/or coexisting forms were associated with increased risk of diarrhoeal diseases in children. An improvement in socioeconomic status, adherence to the continuation of breastfeeding, and maternal education are keys to reducing the burden of diarrhoea among children.

Postnatal supplementation with alarmins S100a8/a9 ameliorates malnutrition-induced neonate enteropathy in mice

Malnutrition is linked to 45% of global childhood mortality, however, the impact of maternal malnutrition on the child's health remains elusive. Previous studies suggested that maternal malnutrition does not affect breast milk composition. Yet, malnourished children often develop a so-called environmental enteropathy, assumed to be triggered by frequent pathogen uptake and unfavorable gut colonization. Here, we show in a murine model that maternal malnutrition induces a persistent inflammatory gut dysfunction in the offspring that establishes during nursing and does not recover after weaning onto standard diet. Early intestinal influx of neutrophils, impaired postnatal development of gut-regulatory functions, and expansion of Enterobacteriaceae were hallmarks of this enteropathy. This gut phenotype resembled those developing under deficient S100a8/a9-supply via breast milk, which is a known key factor for the postnatal development of gut homeostasis. We could confirm that S100a8/a9 is lacking in the breast milk of malnourished mothers and the offspring's intestine. Nutritional supply of S100a8 to neonates of malnourished mothers abrogated the aberrant development of gut mucosal immunity and microbiota colonization and protected them lifelong against severe enteric infections and non-infectious bowel diseases. S100a8 supplementation after birth might be a promising measure to counteract deleterious imprinting of gut immunity by maternal malnutrition.

Intestinal Parasitic Infections May Be Overlooked Drivers of the Tuberculosis Pandemic

The burden of tuberculosis (TB) is disproportionate in tropical and subtropical regions, where parasitic coinfections are common. Given the significant geographical overlap between TB and intestinal parasitic infections, it is important to consider the implications of intestinal parasitic infections for the TB pandemic. Intestinal parasitic infections have been theorized to increase vulnerability to TB by altering the inflammatory milieu, inducing undernutrition that blunts the immune response, and affecting drug pharmacokinetics. In this perspective, we provide a background of the epidemiological and immunological evidence that links parasitic infections to increased risk of TB progression and worse treatment outcomes. We also identify gaps in our knowledge and call for increased research on TB-parasitic coinfections to ensure action on a potentially widespread TB comorbidity.

Multilevel factors drive child exposure to enteric pathogens in animal feces: A qualitative study in northwestern coastal Ecuador

Exposure to animal feces and associated enteric pathogens poses significant risks to child health. However, public health strategies to mitigate enteric infections among children largely aim to reduce exposure to human feces, overlooking transmission pathways related to animal feces. In this study we examine if and how children are exposed to enteric pathogens in animal feces in northwestern coastal Ecuador. We conducted qualitative interviews with mothers of children aged 10-18 months that owned (n = 32) and did not own (n = 26) animals in urban and rural communities. Using thematic analysis, we identified community, household, and child behavioral factors that influence exposure. We also compared child exposure by household animal ownership. Our findings revealed myriad opportunities for young children to be exposed to enteric pathogens in many locations and from multiple animal sources, regardless of household animal ownership. Animal feces management practices (AFM) used by mothers, such as rinsing feces into ditches and throwing feces into surrounding areas, may increase environmental contamination outside their homes and in their communities. Unsafe AFM practices were similar to unsafe child feces management practices reported in other studies, including practices related to defecation location, feces removal and disposal, environmental contamination cleaning, and handwashing. Findings suggest that animal feces may contaminate the environment along similar pathways as human feces. Identification and incorporation of safe AFM practices, similar to those developed for child feces management, would 1) mitigate child exposure to enteric pathogens by reducing animal feces contamination in domestic and public spaces; and 2) enable an integrated approach to address enteric pathogen exposure pathways related to animal and child feces.

Household-level water, sanitation and hygiene factors and interventions and the prevention of relapse after severe acute malnutrition recovery: A systematic review

Severe acute malnutrition (SAM) is the most serious form of acute malnutrition and is associated with high mortality risk among children under 5. While the Community-based Management of Acute Malnutrition (CMAM) approach, recommended for treating cases of uncomplicated SAM, has increased treatment coverage and recovery outcomes, high relapse rates have been reported. Several risk factors for SAM relapse, such as insufficient food intake and high infectious disease burden in the community, have been identified. However, the role of household water, sanitation and hygiene (WASH) conditions remains unclear. This systematic review: (1) assesses the effectiveness of WASH interventions on preventing SAM relapse and (2) identifies WASH-related conditions associated with relapse to SAM among children aged 6-59 months discharged as recovered following SAM CMAM treatment. We performed electronic searches of six databases to identify relevant studies published between 1 January 2000 and 6 November 2023 and assessed their quality. After deduplication, 10,294 documents were screened by title and abstract, with 13 retrieved for full-text screening. We included three studies ranging from low- to medium-quality. One intervention study found that providing a WASH kit during SAM outpatient treatment did not reduce the risk of relapse to SAM. Two observational studies found inconsistent associations between household WASH conditions-unimproved sanitation and unsafe drinking water-and SAM relapse. Despite the paucity of evidence, the hypothesised causal pathways between WASH conditions and the risk of relapse remain plausible. Further evidence is needed to identify interventions for an integrated postdischarge approach to prevent relapse.

The Costly Vicious Cycle of Infections and Malnutrition

Malnutrition, which continues to affect hundreds of millions of people worldwide, is both a cause and consequence of a range of infectious diseases. In this perspective piece, we provide an overview of the bidirectional relationship between malnutrition and infectious diseases. In addition to enteric infections, we use tuberculosis as a case study of this relationship between malnutrition and infectious diseases, and to demonstrate the potential of nutritional interventions to mitigate mortality and morbidity from infectious diseases. We conclude with suggestions on advancing our understanding of the vicious cycle of microbes and malnutrition and finding ways to break it.

Perspective: Connecting the dots between domestic livestock ownership and child linear growth in low- and middle-income countries

Child stunting due to linear growth faltering remains a pervasive issue in low- and middle-income countries. Two schools of thought have existed pertaining to the role of domestic livestock ownership (DLO) in child linear growth. On one hand, it is argued that DLO leads to greater income and financial security, resulting in better child-raising conditions, including greater animal-source food (ASF) consumption, having protective effects towards child stunting. On the other hand, researchers argue that DLO contributes to faecal contamination and transmission of zoonotic enteric infections from animals to children, thus having destructive effects on child growth. Reviews of this association have revealed ambiguous findings. In this perspective, we argue that measuring the association between exposures to domesticated animals and child stunting is difficult and the ambiguous associations revealed are a result of confounding and differences in the management of DLO. We also argue that the increasingly prominent area of research of environmental enteric dysfunction, a sub-clinical condition of the small intestine thought to be due to frequent faecal pathogen exposure and associated with stunting, will be a useful tool to measure the potential destructive effects of DLO on child growth. We present our argument and identify challenges and considerations and directions for future research.

Direct therapeutic effect of sulfadoxine-pyrimethamine on nutritional deficiency-induced enteric dysfunction in a human Intestine Chip

BACKGROUND

Sulfadoxine-pyrimethamine (SP) antimalarial therapy has been suggested to potentially increase the birth weight of infants in pregnant women in sub-Saharan Africa, independently of malarial infection. Here, we utilized female intestinal organoid-derived cells cultured within microfluidic Organ Chips to investigate whether SP could directly impact intestinal function and thereby improve the absorption of essential fats and nutrients crucial for fetal growth.

METHODS

Using a human organ-on-a-chip model, we replicated the adult female intestine with patient organoid-derived duodenal epithelial cells interfaced with human intestinal endothelial cells. Nutrient-deficient (ND) medium was perfused to simulate malnutrition, resulting in the appearance of enteric dysfunction indicators such as villus blunting, reduced mucus production, impaired nutrient absorption, and increased inflammatory cytokine secretion. SP was administered to these chips in the presence or absence of human peripheral blood mononuclear cells (PBMCs).

FINDINGS

Our findings revealed that SP treatment effectively reversed multiple intestinal absorptive abnormalities observed in malnourished female Intestine Chips, as validated by transcriptomic and proteomic analyses. SP also reduced the production of inflammatory cytokines and suppressed the recruitment of PBMCs in ND chips.

INTERPRETATION

Our results indicate that SP could potentially increase birth weights by preventing enteric dysfunction and suppressing intestinal inflammation. This underscores the potential of SP as a targeted intervention to improve maternal absorption, subsequently contributing to healthier fetal growth. While SP treatment shows promise in addressing malabsorption issues that can influence infant birth weight, we did not model pregnancy in our chips, and thus its usefulness for treatment of malnourished pregnant women requires further investigation through clinical trials.

FUNDING

The Bill and Melinda Gates Foundation, and the Wyss Institute for Biologically Inspired Engineering at Harvard University, and the HDDC Organoid Core of the P30 DK034854.

Identification of potential biomarkers in malnutrition children with severity by 1H-NMR-based metabolomics: a preliminary study in the Chinese population

PURPOSE

Child malnutrition is a global public health problem, but the underlying pathophysiologic mechanisms with severity remain poorly understood, and the potential biomarkers served to the clinical diagnosis are still not available. This study aimed to identify the serum metabolic characteristics of malnourished children with severity.

METHODS

Fasted overnight serum samples were collected following clinical standard procedures among 275 malnourished and 199 healthy children from the Women and Children's Hospital, Xiamen University Child Health Department from July 2020 to May 2022. Nuclear magnetic resonance (NMR)-based metabolomics strategy was applied to identify the potential serum biomarkers of malnutrition from 275 malnourished children aged 4 to 84 months with mild (Mil, 199 cases), moderate (Mod, 101 cases), and severe (Sev, 7 cases) malnutrition.

RESULTS

Ten, fifteen, and fifteen differential metabolites were identified from the Mil, Mod, and Sev malnutrition groups, respectively. Eight common metabolites, including increased acetoacetate, acetone, ethanol, succinate, 3-hydroxybutyrate, and decreased alanine, methionine, and N-acetyl-glycoprotein, could be the potential biomarkers for malnourished children. The altered metabolic pathways were mainly related to energy metabolism and amino acid metabolism via the network-based pathway enrichment.

CONCLUSION

Eight potential biomarkers, including acetoacetate, acetone, ethanol, succinate, 3-hydroxybutyrate, alanine, methionine, and N-acetyl-glycoprotein, could characterize the child malnutrition. Child malnutrition-induced abnormal energy metabolism, impaired nutrition utilization and the reduced nutrient availability, and more metabolic disturbance will appear with the severity. Our results are valuable for further studies on the etiology and pathogenesis of malnutrition for clinical intervention and improvement.

Inflammation: the driver of poor outcomes among children with severe acute malnutrition?

Severe acute malnutrition (SAM) is the most life-threatening form of undernutrition and underlies at least 10% of all deaths among children younger than 5 years in low-income countries. SAM is a complex, multisystem disease, with physiological perturbations observed in conjunction with the loss of lean mass, including structural and functional changes in many organ systems. Despite the high mortality burden, predominantly due to infections, the underlying pathogenic pathways remain poorly understood. Intestinal and systemic inflammation is heightened in children with SAM. Chronic inflammation and its consequent immunomodulation may explain the increased morbidity and mortality from infections in children with SAM, both during hospitalization and in the longer term after discharge. Recognition of the role of inflammation in SAM is critical in considering new therapeutic targets in this disease, which has not seen a transformational approach to treatment for several decades. This review highlights the central role of inflammation in the wide-ranging pathophysiology of SAM, as well as identifying potential interventions that have biological plausibility based on evidence from other inflammatory syndromes.

Safety, tolerability, and immunogenicity of an oral inactivated ETEC vaccine (ETVAX®) with dmLT adjuvant in healthy adults and children in Zambia: An age descending randomised, placebo-controlled trial

BACKGROUND

Enterotoxigenic Escherichia coli (ETEC) is an important cause of moderate to severe diarrhoea in children for which there is no licensed vaccine. We evaluated ETVAX®, an oral, inactivated ETEC vaccine containing four E. coli strains over-expressing the major colonization factors CFA/I, CS3, CS5, and CS6, a toxoid (LCTBA) and double mutant heat-labile enterotoxin (dmLT) adjuvant for safety, tolerability, and immunogenicity.

METHODS

A double-blind, placebo-controlled, age-descending, dose-finding trial was undertaken in 40 adults, 60 children aged 10-23 months, and 146 aged 6-9 months. Adults received one full dose of ETVAX® and children received 3 doses of either 1/4 or 1/8 dose. Safety was evaluated as solicited and unsolicited events for 7 days following vaccination. Immunogenicity was assessed by evaluation of plasma IgA antibody responses to CFA/I, CS3, CS5, CS6, and LTB, and IgG responses to LTB.

RESULTS

Solicited adverse events were mostly mild or moderate with only 2 severe fever reports which were unrelated to the vaccine. The most common events were abdominal pain in adults (26.7 % in vaccinees vs 20 % in placebos), and fever in children aged 6-9 months (44 % vs 54  %). Dosage, number of vaccinations and decreasing age had no influence on severity or frequency of adverse events. The vaccine induced plasma IgA and IgG responses against LTB in 100 % of the adults and 80-90 % of the children. In the 6-23 months cohort, IgA responses to more than 3 vaccine antigens after 3 doses determined as ≥2-fold rise was significantly higher for 1/4 dose compared to placebo (56.7 % vs 27.2 %, p = 0.01). In the 6-9 months cohort, responses to the 1/4 dose were significantly higher than 1/8 dose after 3 rather than 2 doses.

CONCLUSION

ETVAX® was safe, tolerable, and immunogenic in Zambian adults and children. The 1/4 dose induced significantly stronger IgA responses and is recommended for evaluation of protection in children.

CLINICAL TRIALS REGISTRATION

The trial is registered with the Pan African Clinical Trials Registry (PACTR Ref. 201905764389804) and a description of this clinical trial is available on: https://pactr.samrc.ac.za/Trial Design.

Quantitative whole-tissue 3D imaging reveals bacteria in close association with mouse jejunum mucosa

Because the small intestine (SI) epithelium lacks a thick protective mucus layer, microbes that colonize the thin SI mucosa may exert a substantial effect on the host. For example, bacterial colonization of the human SI may contribute to environmental enteropathy dysfunction (EED) in malnourished children. Thus far, potential bacterial colonization of the mucosal surface of the SI has only been documented in disease states, suggesting mucosal colonization is rare, likely requiring multiple perturbations. Furthermore, conclusive proof of bacterial colonization of the SI mucosal surface is challenging, and the three-dimensional (3D) spatial structure of mucosal colonies remains unknown. Here, we tested whether we could induce dense bacterial association with jejunum mucosa by subjecting mice to a combination of malnutrition and oral co-gavage with a bacterial cocktail (E. coli and Bacteroides spp.) known to induce EED. To visualize these events, we optimized our previously developed whole-tissue 3D imaging tools with third-generation hybridization chain reaction (HCR v3.0) probes. Only in mice that were malnourished and gavaged with the bacterial cocktail did we detect dense bacterial clusters surrounding intestinal villi suggestive of colonization. Furthermore, in these mice we detected villus loss, which may represent one possible consequence that bacterial colonization of the SI mucosa has on the host. Our results suggest that dense bacterial colonization of jejunum mucosa is possible in the presence of multiple perturbations and that whole-tissue 3D imaging tools can enable the study of these rare events.

Relapse of severe acute malnutrition among children discharged from outpatient therapeutic program in western Ethiopia

BACKGROUND

Children with severe acute malnutrition (SAM) without complication are treated in the outpatient therapeutic program (OTP) and the program has been reported to be effective. However, relapse post-discharge from the program is poorly defined, and scarcely evaluated across programs and research. The objective of this study is to assess the prevalence of SAM among children post-discharge from the OTP and to identify factors associated with SAM relapse in Gambella Region, Western Ethiopia.

METHODS

We conducted a facility-based cross-sectional study among 208 children aged 6-59 months who have been discharged from the OTP as cured. Baseline data were collected from caregivers using structured questionnaire. Child anthropometry and oedema was measured. The association between SAM relapse and the risk factors were assessed using bivariate and multivariable logistic regression models.

RESULTS

The prevalence of SAM relapse was 10.1% (95% CI: 5.8-14.0%). The odds of SAM relapse was significantly higher in children with mothers who had no exposure to education and promotion about infant and young child feeding (IYCF) practices (OR = 5.7; 95% CI: 1.3-12.6), children who were not fully immunized for their age (OR = 8.0; 95% CI: 3.8-23.4), and children with mid-upper arm circumference (MUAC) at discharge of < 12.5 cm (OR = 4.4; 95% CI: 2.1-12.8) than their counterparts.

CONCLUSIONS

To reduce SAM relapse, the OTP programs should avoid premature discharge and consider provision of supplementary food for children with low MUAC at discharge. Further, the OTP discharge criteria should consider both the anthropometric indicators - weight-for-height/length z-score (WHZ) and MUAC - and the absence of bilateral pitting oedema irrespective of the anthropometric indicator that is used during admission. Promotion of nutrition education and improving child immunization services and coverage would help reduce SAM relapse.

Population genomics of diarrheagenic Escherichia coli uncovers high connectivity between urban and rural communities in Ecuador

Human movement may be an important driver of transmission dynamics for enteric pathogens but has largely been underappreciated except for international 'travelers' diarrhea or cholera. Phylodynamic methods, which combine genomic and epidemiological data, are used to examine rates and dynamics of disease matching underlying evolutionary history and biogeographic distributions, but these methods often are not applied to enteric bacterial pathogens. We used phylodynamics to explore the phylogeographic and evolutionary patterns of diarrheagenic E. coli in northern Ecuador to investigate the role of human travel in the geographic distribution of strains across the country. Using whole genome sequences of diarrheagenic E. coli isolates, we built a core genome phylogeny, reconstructed discrete ancestral states across urban and rural sites, and estimated migration rates between E. coli populations. We found minimal structuring based on site locations, urban vs. rural locality, pathotype, or clinical status. Ancestral states of phylogenomic nodes and tips were inferred to have 51% urban ancestry and 49% rural ancestry. Lack of structuring by location or pathotype E. coli isolates imply highly connected communities and extensive sharing of genomic characteristics across isolates. Using an approximate structured coalescent model, we estimated rates of migration among circulating isolates were 6.7 times larger for urban towards rural populations compared to rural towards urban populations. This suggests increased inferred migration rates of diarrheagenic E. coli from urban populations towards rural populations. Our results indicate that investments in water and sanitation prevention in urban areas could limit the spread of enteric bacterial pathogens among rural populations.

Inflammatory profiles in febrile children with moderate and severe malnutrition presenting at-hospital in Uganda are associated with increased mortality

BACKGROUND

Children in Africa carry a disproportionate burden of malnutrition and infectious disease. Together, malnutrition and infection are major contributors to global child mortality; however, their collective impact on immune activation are not well described.

METHODS

This was a secondary analysis of a prospective cohort study of children hospitalized with acute febrile illness at a single centre in Uganda. We investigated the association between malnutrition (determined using the mid-upper arm circumference, MUAC), immune activation (as measured by inflammatory markers IL-6, IL-8, CXCL10, CHI3L1, sTNFR1, Cystatin C, granzyme B, and sTREM-1), and mortality.

FINDINGS

Of the 1850 children eligible for this secondary analysis, 71 (3.8%) and 145 (11.7%) presented with severe acute malnutrition (SAM, MUAC <115 mm) and moderate malnutrition (MUAC 115 to < 125 mm), respectively. SAM was associated with increased concentrations of CHI3L1, sTNFR1, Cystatin C, and sTREM-1, and decreased concentrations of CXCL10 and granzyme B, even after controlling for age, sex, and disease severity at presentation. There were 77 deaths (4.2%). SAM was associated with a 9.2-fold (95% CI 4.8-46), 17-fold (95% CI 3.9-74), and 13-fold (95% CI 3.5-52) increased odds of death in children with pneumonia, malaria, and diarrheal illness, respectively. Mediation analysis implicated sTREM-1 and CHI3L1 in the effect of SAM on mortality, suggesting that enhanced activation of these inflammatory pathways is associated with the increased mortality in undernourished children with pneumonia and malaria.

INTERPRETATION

Collectively, these data highlight systemic inflammation as a common pathway associated with malnutrition and infection that could be targeted to mitigate the burden of acute febrile illness in LMICs.

FUNDING

This work was supported in part by the Canadian Institutes of Health Research, and by kind donations from The Tesari Foundation and Kim Kertland. The funders had no role in design, analysis, or reporting of these studies.

Prevalence and Load of the Campylobacter Genus in Infants and Associated Household Contacts in Rural Eastern Ethiopia: a Longitudinal Study from the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) Project

In our previous cross-sectional study, multiple species of Campylobacter were detected (88%) in stool samples from children (12 to 14 months of age) in rural eastern Ethiopia. This study assessed the temporal fecal carriage of Campylobacter in infants and identified putative reservoirs associated with these infections in infants from the same region. The prevalence and load of Campylobacter were determined using genus-specific real-time PCR. Stool samples from 106 infants (n = 1,073) were collected monthly from birth until 376 days of age (DOA). Human stool samples (mothers and siblings), livestock feces (cattle, chickens, goats, and sheep), and environmental samples (soil and drinking water) from the 106 households were collected twice per household (n = 1,644). Campylobacter was most prevalent in livestock feces (goats, 99%; sheep, 98%; cattle, 99%; chickens, 93%), followed by human stool samples (siblings, 91%; mothers, 83%; infants, 64%) and environmental samples (soil, 58%; drinking water, 43%). The prevalence of Campylobacter in infant stool samples significantly increased with age, from 30% at 27 DOA to 89% at 360 DOA (1% increase/day in the odds of being colonized) (P < 0.001). The Campylobacter load increased linearly (P < 0.001) with age from 2.95 logs at 25 DOA to 4.13 logs at 360 DOA. Within a household, the Campylobacter load in infant stool samples was positively correlated with the load in mother stool samples (r2 = 0.18) and soil collected inside the house (r2 = 0.36), which were in turn both correlated with Campylobacter loads in chicken and cattle feces (0.60 < r2 < 0.63) (P < 0.01). In conclusion, a high proportion of infants are infected with Campylobacter in eastern Ethiopia, and contact with the mother and contaminated soil may be associated with early infections. IMPORTANCE A high Campylobacter prevalence during early childhood has been associated with environmental enteric dysfunction (EED) and stunting, especially in low-resource settings. Our previous study demonstrated that Campylobacter was frequently found (88%) in children from eastern Ethiopia; however, little is known about potential Campylobacter reservoirs and transmission pathways leading to infection of infants by Campylobacter during early growth. In the longitudinal study presented here, Campylobacter was frequently detected in infants within the 106 surveyed households from eastern Ethiopia, and the prevalence was age dependent. Furthermore, preliminary analyses highlighted the potential role of the mother, soil, and livestock in the transmission of Campylobacter to the infant. Further work will explore the species and genetic composition of Campylobacter in infants and putative reservoirs using PCR and whole-genome and metagenomic sequencing. The findings from these studies can lead to the development of interventions to minimize the risk of transmission of Campylobacter to infants and, potentially, EED and stunting.

Feature selection and association rule learning identify risk factors of malnutrition among Ethiopian schoolchildren

Introduction

Previous studies have sought to identify risk factors for malnutrition in populations of schoolchildren, depending on traditional logistic regression methods. However, holistic machine learning (ML) approaches are emerging that may provide a more comprehensive analysis of risk factors.

Methods

This study employed feature selection and association rule learning ML methods in conjunction with logistic regression on epidemiological survey data from 1,036 Ethiopian school children. Our first analysis used the entire dataset and then we reran this analysis on age, residence, and sex population subsets.

Results

Both logistic regression and ML methods identified older childhood age as a significant risk factor, while females and vaccinated individuals showed reduced odds of stunting. Our machine learning analyses provided additional insights into the data, as feature selection identified that age, school latrine cleanliness, large family size, and nail trimming habits were significant risk factors for stunting, underweight, and thinness. Association rule learning revealed an association between co-occurring hygiene and socio-economical variables with malnutrition that was otherwise missed using traditional statistical methods.

Discussion

Our analysis supports the benefit of integrating feature selection methods, association rules learning techniques, and logistic regression to identify comprehensive risk factors associated with malnutrition in young children.

Symptomatic and Asymptomatic Campylobacter Infections and Child Growth in South Asia: Analyzing Data from the Global Enteric Multicenter Study

Campylobacter is a major cause of food-borne gastrointestinal illnesses worldwide, predominantly affecting children under 5 years of age. This study examined potential associations of symptomatic (with diarrhea) and asymptomatic (without diarrhea) Campylobacter infections with child growth among children under 5 years of age in South Asia. The Global Enteric Multicenter Study was conducted from 2007 to 2011 with a case-control design. Children were followed for 60 days after enrollment. Stool culture was performed to isolate Campylobacter spp. Among the 22,567 enrolled children, 9,439 were symptomatic, with 786 (8.28%) testing positive for Campylobacter. Conversely, 13,128 asymptomatic healthy controls were included, with 1,057 (8.05%) testing positive for Campylobacter. Growth faltering was observed in the symptomatic group, particularly among children aged 0-11 months (-0.19 height-for-age z score [HAZ]; 95% CI: -0.36, -0.03; P = 0.018) and 24-59 months (-0.16 HAZ; 95% CI: -0.28, -0.04; P = 0.010). However, in the asymptomatic group, growth faltering was observed only in the 24- to 59-month age group, in terms of HAZ (-0.15 HAZ; 95% CI: -0.24, -0.05; P = 0.002) and weight-for-height z score (-0.16; 95% CI: -0.26, -0.06; P = 0.001). These findings underscore the importance of immediate and enhanced introduction of preventive modalities to reduce the burden of Campylobacter infections and reduce their long-term sequelae.

Effects of High Temperature and Heavy Precipitation on Drinking Water Quality and Child Hand Contamination Levels in Rural Kenya

Climate change may impact human health through the influence of weather on environmental transmission of diarrhea. Previous studies have found that high temperatures and heavy precipitation are associated with increased diarrhea prevalence, but the underlying causal mechanisms have not been tested and validated. We linked measurements of Escherichia coli in source water (n = 1673), stored drinking water (n = 9692), and hand rinses from children <2 years old (n = 2634) with publicly available gridded temperature and precipitation data (at ≤0.2 degree spatial resolution and daily temporal resolution) by the GPS coordinates and date of sample collection. Measurements were collected over a 3-year period across a 2500 km² area in rural Kenya. In drinking water sources, high 7-day temperature was associated with a 0.16 increase in log₁₀ E. coli levels (p < 0.001, 95% CI: 0.07, 0.24), while heavy 7-day total precipitation was associated with a 0.29 increase in log₁₀ E. coli levels (p < 0.001, 95% CI: 0.13, 0.44). In household stored drinking water, heavy 7-day precipitation was associated with a 0.079 increase in log₁₀ E. coli levels (p = 0.042, 95% CI: 0.07, 0.24). Heavy precipitation did not increase E. coli levels among respondents who treated their water, suggesting that water treatment can mitigate effects on water quality. On child hands, high 7-day temperature was associated with a 0.39 decrease in log₁₀ E. coli levels (p < 0.001, 95% CI: -0.52, -0.27). Our findings provide insight on how climate change could impact environmental transmission of bacterial pathogens in Kenya. We suggest water treatment is especially important after heavy precipitation (particularly when preceded by dry periods) and high temperatures.

Long-Term Transcriptomic Changes and Cardiomyocyte Hyperpolyploidy after Lactose Intolerance in Neonatal Rats

Many cardiovascular diseases originate from growth retardation, inflammation, and malnutrition during early postnatal development. The nature of this phenomenon is not completely understood. Here we aimed to verify the hypothesis that systemic inflammation triggered by neonatal lactose intolerance (NLI) may exert long-term pathologic effects on cardiac developmental programs and cardiomyocyte transcriptome regulation. Using the rat model of NLI triggered by lactase overloading with lactose and the methods of cytophotometry, image analysis, and mRNA-seq, we evaluated cardiomyocyte ploidy, signs of DNA damage, and NLI-associated long-term transcriptomic changes of genes and gene modules that differed qualitatively (i.e., were switched on or switched off) in the experiment vs. the control. Our data indicated that NLI triggers the long-term animal growth retardation, cardiomyocyte hyperpolyploidy, and extensive transcriptomic rearrangements. Many of these rearrangements are known as manifestations of heart pathologies, including DNA and telomere instability, inflammation, fibrosis, and reactivation of fetal gene program. Moreover, bioinformatic analysis identified possible causes of these pathologic traits, including the impaired signaling via thyroid hormone, calcium, and glutathione. We also found transcriptomic manifestations of increased cardiomyocyte polyploidy, such as the induction of gene modules related to open chromatin, e.g., "negative regulation of chromosome organization", "transcription" and "ribosome biogenesis". These findings suggest that ploidy-related epigenetic alterations acquired in the neonatal period permanently rewire gene regulatory networks and alter cardiomyocyte transcriptome. Here we provided first evidence indicating that NLI can be an important trigger of developmental programming of adult cardiovascular disease. The obtained results can help to develop preventive strategies for reducing the NLI-associated adverse effects of inflammation on the developing cardiovascular system.

Association between diet history and symptoms of individuals having recovered from COVID-19

BACKGROUND

Many studies show that people who eat a balanced diet have stronger immunity. The present work aimed to identify the effects of the diet history of COVID-19 patients having recovered from the disease on the occurrence and severity of symptoms.

METHODS

The study sample consisted of 346 individuals aged 20-65 years. The participants' data and answers to an electronic questionnaire regarding their diet history and symptoms were collected. The study focused on four hard symptoms (fever, body pain, cough, and dyspnoea) to investigate the relationship between these symptoms and the consumption of specific immunity foods.

RESULTS

Symptoms were reported by 88.1% of the participants eating none of the foods investigated, whereas 85.54% and 85.55% of the individuals with little or intensive food intake, respectively, experienced symptoms.

CONCLUSIONS

Intake of specific functional foods might slightly reduce the occurrence of some symptoms.

Association of Circulating Biomarkers with Growth and Cognitive Development in Rural Tanzania: A Secondary Analysis of the Early Life Interventions in Childhood Growth and Development In Tanzania (ELICIT) Study

BACKGROUND

Children in low-resource areas experience nutritional and infection challenges delaying growth and cognitive development.

OBJECTIVE

Our goal was to assess for associations of circulating biomarkers related to nutrition and inflammation, with growth and developmental outcomes among children in a birth cohort in a resource-poor area in rural Tanzania.

METHODS

We assessed data from 1120 children participating in the Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT) study. At age 12 and 18 months participants had blood tests performed for hemoglobin, collagen-X, insulin-like growth factor-1 (IGF-1), fibroblast growth-factor-21 (FGF21), thyroglobulin, ferritin, soluble transferrin receptor (sTFR), retinol binding protein-4 (RBP4), C-reactive protein (CRP), alpha(1)-acid glycoprotein (AGP), and CD14. At 18 months, participants had anthropometry measured and converted to z-scores for length-for-age (LAZ), weight-for-age (WAZ) and head-circumference-for-age (HCZ) and had the Malawi Developmental Assessment Tool (MDAT) performed to evaluate cognitive development. We performed linear regression assessing biomarkers (predictor variable) on anthropometry and MDAT scores (dependent variables), adjusted for sex, socioeconomic status and baseline values.

RESULTS

There was a high degree of intra-factor correlation between 12 and 18 months, and inter-factor correlation between biomarkers. IGF-1 and sTFR were positively- and FGF21 and ferritin negatively-associated with LAZ 18 months, while collagen-X and CD14 were additionally associated with recent linear growth. Only markers predominantly related to nutrition were consistently linked with WAZ at 18 months, while RBP4 and AGP were additionally associated with recent change in WAZ. IGF-1 was positively- and thyroglobulin, RBP4 and CD14 negatively linked to MDAT scores. IGF-1 was the only factor linked to both 18-month LAZ and MDAT.

CONCLUSIONS

Individual biomarkers were consistently linked to growth and cognitive outcomes, providing support for relationships between nutrition and inflammation in early child development. Further research is needed to assess overlaps in how biomarker-related processes interact with both growth and learning.

Study design and rationale for the PAASIM project: a matched cohort study on urban water supply improvements and infant enteric pathogen infection, gut microbiome development and health in Mozambique

INTRODUCTION

Despite clear linkages between provision of clean water and improvements in child health, limited information exists about the health impacts of large water infrastructure improvements in low-income settings. Billions of dollars are spent annually to improve urban water supply, and rigorous evaluation of these improvements, especially targeting informal settlements, is critical to guide policy and investment strategies. Objective measures of infection and exposure to pathogens, and measures of gut function, are needed to understand the effectiveness and impact of water supply improvements.

METHODS AND ANALYSIS

In the PAASIM study, we examine the impact of water system improvements on acute and chronic health outcomes in children in a low-income urban area of Beira, Mozambique, comprising 62 sub-neighbourhoods and ~26 300 households. This prospective matched cohort study follows 548 mother-child dyads from late pregnancy through 12 months of age. Primary outcomes include measures of enteric pathogen infections, gut microbiome composition and source drinking water microbiological quality, measured at the child's 12-month visit. Additional outcomes include diarrhoea prevalence, child growth, previous enteric pathogen exposure, child mortality and various measures of water access and quality. Our analyses will compare (1) subjects living in sub-neighbourhoods with the improved water to those living in sub-neighbourhoods without these improvements; and (2) subjects with household water connections on their premises to those without such a connection. This study will provide critical information to understand how to optimise investments for improving child health, filling the information gap about the impact of piped water provision to low-income urban households, using novel gastrointestinal disease outcomes.

ETHICS AND DISSEMINATION

This study was approved by the Emory University Institutional Review Board and the National Bio-Ethics Committee for Health in Mozambique. The pre-analysis plan is published on the Open Science Framework platform (https://osf.io/4rkn6/). Results will be shared with relevant stakeholders locally, and through publications.

Parasites and childhood stunting - a mechanistic interplay with nutrition, anaemia, gut health, microbiota, and epigenetics

Globally, stunting affects approximately 149.2 million children under 5 years of age. The underlying aetiology and pathophysiological mechanisms leading to stunting remain elusive, and therefore few effective treatment and prevention strategies exist. Crucial evidence directly linking parasites to stunting is often lacking - in part due to the complex nature of stunting, as well as a lack of critical multidisciplinary research amongst key age groups. Here, based on available studies, we present potential mechanistic pathways by which parasitic infection of mother and/or infant may lead to childhood stunting. We highlight the need for future multidisciplinary longitudinal studies and clinical trials aimed at elucidating the most influential factors, and synergies therein, that can lead to stunting, and ultimately towards finding solutions to successfully mitigate against it.

Tyrosol inhibits NF-κB pathway in the treatment of enterotoxigenic Escherichia coli-induced diarrhea in mice

Tyrosol is one of the main polyphenol compounds in white wine and extra virgin olive oil (EVOO), which plays an antioxidant and anti-inflammatory role in vitro. In the present study, we investigated the possible anti-inflammatory mechanism of tyrosol in Escherichia coli (ETEC)-induced diarrhea in mice. ICR mice were randomly divided into control group, ETEC group, and ETEC + Tyrosol group with 10 mice in each group. In addition to the control group, a bacterial diarrhea model was induced in mice by continuous administration of 0.2 ml × 10⁹ CFU/ml ETEC. After 7 days, the ETEC + Tyrosol group was given tyrosol (20 mg/kg) once a day by gavage, during which the body weight of mice and the degree of diarrhea were measured daily. On the 15th day, all animals in this experiment were sacrificed, colon tissue was collected, and colon length was recorded. Our results indicate that tyrosol significantly attenuated the extent of ETEC-induced diarrhea, including inhibition of pro-inflammatory cytokine, repair of the intestinal epithelial mechanical barrier, and significant inhibition of NF-κB activation. This finding is helpful for the development and further application of tyrosol in the treatment of diarrhea.

The modulatory effect of encapsulated bioactives and probiotics on gut microbiota: improving health status through functional food

The gut microbiota can be a determining factor of the health status of the host by its association with some diseases. It is known that dietary intake can modulate this microbiota through the consumption of compounds like essential oils, unsaturated fatty acids, non-digestible fiber, and probiotics, among others. However, these kinds of compounds can be damaged in the gastrointestinal tract as they pass through it to reach the intestine. This is due to the aggressive and changing conditions of this tract. For this reason, to guarantee that compounds arrive in the intestine at an adequate concentration to exert a modulatory effect on the gut microbiota, encapsulation should be sought. In this paper, we review the current research on compounds that modulate the gut microbiota, the encapsulation techniques used to protect the compounds through the gastrointestinal tract, in vitro models of this tract, and how these encapsulates interact with the gut microbiota. Finally, an overview of the regulatory status of these encapsulates is presented. The key findings are that prebiotics are the best modulators of gut microbiota fermentation metabolites. Also, probiotics promote an increase of beneficial gut microorganisms, which in some cases promotes their fermentation metabolites as well. Spray drying, freeze drying, and electrodynamics are notable encapsulation techniques that permit high encapsulation efficiency, high viability, and, together with wall materials, a high degree of protection against gastrointestinal conditions, allowing controlled release in the intestine and exerting a modulatory effect on gut microbiota.

1H-NMR-Based Metabolomics in Autism Spectrum Disorder and Pediatric Acute-Onset Neuropsychiatric Syndrome

We recently described a unique plasma metabolite profile in subjects with pediatric acute-onset neuropsychiatric syndrome (PANS), suggesting pathogenic models involving specific patterns of neurotransmission, neuroinflammation, and oxidative stress. Here, we extend the analysis to a group of patients with autism spectrum disorder (ASD), as a consensus has recently emerged around its immune-mediated pathophysiology with a widespread involvement of brain networks. This observational case-control study enrolled patients referred for PANS and ASD from June 2019 to May 2020, as well as neurotypical age and gender-matched control subjects. Thirty-four PANS outpatients, fifteen ASD outpatients, and twenty-five neurotypical subjects underwent physical and neuropsychiatric evaluations, alongside serum metabolomic analysis with 1H-NMR. In supervised models, the metabolomic profile of ASD was significantly different from controls (p = 0.0001), with skewed concentrations of asparagine, aspartate, betaine, glycine, lactate, glucose, and pyruvate. Metabolomic separation was also observed between PANS and ASD subjects (p = 0.02), with differences in the concentrations of arginine, aspartate, betaine, choline, creatine phosphate, glycine, pyruvate, and tryptophan. We confirmed a unique serum metabolomic profile of PANS compared with both ASD and neurotypical subjects, distinguishing PANS as a pathophysiological entity per se. Tryptophan and glycine appear as neuroinflammatory fingerprints of PANS and ASD, respectively. In particular, a reduction in glycine would primarily affect NMDA-R excitatory tone, overall impairing downstream glutamatergic, dopaminergic, and GABAergic transmissions. Nonetheless, we found metabolomic similarities between PANS and ASD that suggest a putative role of N-methyl-D-aspartate receptor (NMDA-R) dysfunction in both disorders. Metabolomics-based approaches could contribute to the identification of novel ASD and PANS biomarkers.

Evolution of infant feeding practices in children from 9 to 24 months, considering complementary feeding indicators and food processing: Results from the Brazilian cohort of the MAL‐ED study

Infant feeding practices impact children's nutritional and health status, influencing growth and development. This study aimed to analyse the evolution of infant feeding practices from 9 to 24 months of age, considering infant and young child feeding (IYCF) indicators and food processing. The infant feeding practices in children from the Brazilian site of the MAL‐ED study were evaluated at 9 (n = 193), 15 (n = 182) and 24 months (n = 164) using 24‐h dietary recalls. IYCF indicators were evaluated, and the extent of food processing was evaluated, using the NOVA classification. Breastfeeding declined significantly over time, from 77.6% at 9 months to 45.1% at 24 months. Although dietary diversity did not significantly change during the study period (80.5% at 24 months), the minimum acceptable diet significantly increased from 67.9% to 76.1% at 24 months (p < 0.0005). All the studied children consumed sweetened beverages from 9 months. Unhealthy food consumption and zero vegetable or fruit consumption significantly increased over time (p < 0.0005). Unprocessed food consumption decreased from 9 to 24 months of age (p < 0.0005), while ultra‐processed food consumption increased (p < 0.0005) during the study period. Logistic regressions showed that, at 9 months, breastfed children presented a lower risk for ultra‐processed food consumption (odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.13–0.77); and children reaching the minimum acceptable diet presented more risk for ultra‐processed food consumption (OR = 2.31; 95% CI = 1.01–5.27). In conclusion, data showed a reduction in the quality of infant feeding practices over the first 2 years of life, with a decrease in breastfeeding and an increase in the consumption of unhealthy and ultra‐processed foods.

Data showed a reduction in the quality of infant feeding practices over the first 2 years of life.

Breastfeeding decreased over the studied period. There was an increase in the consumption of ultra‐processed and unhealthy foods, which occurred concomitantly to the increase of no consumption of fruits/vegetables.

Breastfeeding was an important protective factor against a greater consumption of ultra‐processed food.

National nutrition policy should consider promoting breastfeeding and increasing fresh and minimally processed food consumption in children under 2 years.

The Combined Escherichia coli Nissle 1917 and Tryptophan Treatment Modulates Immune and Metabolome Responses to Human Rotavirus Infection in a Human Infant Fecal Microbiota-Transplanted Malnourished Gnotobiotic Pig Model

Human rotavirus (HRV) is a major cause of childhood diarrhea in developing countries where widespread malnutrition contributes to the decreased oral vaccine efficacy and increased prevalence of other enteric infections, which are major concerns for global health. Neonatal gnotobiotic (Gn) piglets closely resemble human infants in their anatomy, physiology, and outbred status, providing a unique model to investigate malnutrition, supplementations, and HRV infection. To understand the molecular signatures associated with immune enhancement and reduced diarrheal severity by Escherichia coli Nissle 1917 (EcN) and tryptophan (TRP), immunological responses and global nontargeted metabolomics and lipidomics approaches were investigated on the plasma and fecal contents of malnourished pigs transplanted with human infant fecal microbiota and infected with virulent (Vir) HRV. Overall, EcN + TRP combined (rather than individual supplement action) promoted greater and balanced immunoregulatory/immunostimulatory responses associated with greater protection against HRV infection and disease in malnourished humanized piglets. Moreover, EcN + TRP treatment upregulated the production of several metabolites with immunoregulatory/immunostimulatory properties: amino acids (N-acetylserotonin, methylacetoacetyl-CoA), lipids (gamma-butyrobetaine, eicosanoids, cholesterol-sulfate, sphinganine/phytosphingosine, leukotriene), organic compound (biliverdin), benzenoids (gentisic acid, aminobenzoic acid), and nucleotides (hypoxathine/inosine/xanthine, cytidine-5'-monophosphate). Additionally, the levels of several proinflammatory metabolites of organic compounds (adenosylhomocysteine, phenylacetylglycine, urobilinogen/coproporphyrinogen) and amino acid (phenylalanine) were reduced following EcN + TRP treatment. These results suggest that the EcN + TRP effects on reducing HRV diarrhea in neonatal Gn pigs were at least in part due to altered metabolites, those involved in lipid, amino acid, benzenoids, organic compounds, and nucleotide metabolism. Identification of these important mechanisms of EcN/TRP prevention of HRV diarrhea provides novel targets for therapeutics development. IMPORTANCE Human rotavirus (HRV) is the most common cause of viral gastroenteritis in children, especially in developing countries, where the efficacy of oral HRV vaccines is reduced. Escherichia coli Nissle 1917 (EcN) is used to treat enteric infections and ulcerative colitis while tryptophan (TRP) is a biomarker of malnutrition, and its supplementation can alleviate intestinal inflammation and normalize intestinal microbiota in malnourished hosts. Supplementation of EcN + TRP to malnourished humanized gnotobiotic piglets enhanced immune responses and resulted in greater protection against HRV infection and diarrhea. Moreover, EcN + TRP supplementation increased the levels of immunoregulatory/immunostimulatory metabolites while decreasing the production of proinflammatory metabolites in plasma and fecal samples. Profiling of immunoregulatory and proinflammatory biomarkers associated with HRV perturbations will aid in the identification of treatments against HRV and other enteric diseases in malnourished children.

Infection With Escherichia Coli Pathotypes Is Associated With Biomarkers of Gut Enteropathy and Nutritional Status Among Malnourished Children in Bangladesh

Escherichia coli (E. coli) pathotypes are the most common cause of diarrhea, especially in developing countries. Environmental Enteric Dysfunction (EED) is presumed to be the result of infection with one or more pathotypes and can affect intestinal health and childhood growth. We sought to investigate the association of E. coli pathotypes infection with biomarkers of EED and nutritional status among slum-dwelling malnourished children in Bangladesh. This study comprised a total of 1050 stunted and at risk of stunting children. TaqMan Array Card assays were used to determine the presence of E. coli pathotypes in feces. Prevalence of infection with EAEC was highest (68.8%) in this cohort of children, followed by EPEC (55.9%), ETEC (44%), Shigella/EIEC (19.4%) and STEC (3.2%). The levels of myeloperoxidase and calprotectin were significantly higher in EAEC (P=0.02 and P=0.04), EPEC (P=0.02 and P=0.03) and Shigella/EIEC (P=0.05 and P=0.02) positive participants while, only calprotectin was significantly higher in ETEC (P=0.01) positive participants. Reg1B was significantly higher in participants with EAEC (P=0.004) while, neopterin levels were significantly lower in ETEC (P=0.003) and Shigella/EIEC (P=0.003) positive cases. A significant positive relationship was observed between EAEC and fecal levels of Reg1B (β = 0.28; 95% CI = 0.12, 0.43; p-value<0.001). Besides, ETEC was found to be positively and significantly associated with the levels of calprotectin (β = 0.14; 95 percent CI = 0.01, 0.26; p-value=0.037) and negatively with neopterin (β = -0.16; 95% CI = -0.30, -0.02; p-value=0.021). On the other hand, infection with EPEC was found to be negatively associated with length-for-age (β = -0.12; 95% CI = -0.22, -0.03; p-value=0.011) and weight-for-age (β = -0.11; 95% CI = -0.22, -0.01; p-value=0.037). The study findings suggest that infection with certain E. coli pathotypes (EAEC and ETEC) influences gut health and EPEC is associated with linear growth and underweight in Bangladeshi children.

Mechanisms of Kwashiorkor-Associated Immune Suppression: Insights From Human, Mouse, and Pig Studies

Malnutrition refers to inadequate energy and/or nutrient intake. Malnutrition exhibits a bidirectional relationship with infections whereby malnutrition increases risk of infections that further aggravates malnutrition. Severe malnutrition (SM) is the main cause of secondary immune deficiency and mortality among children in developing countries. SM can manifest as marasmus (non-edematous), observed most often (68.6% of all malnutrition cases), kwashiorkor (edematous), detected in 23.8% of cases, and marasmic kwashiorkor, identified in ~7.6% of SM cases. Marasmus and kwashiorkor occur due to calorie-energy and protein-calorie deficiency (PCD), respectively. Kwashiorkor and marasmic kwashiorkor present with reduced protein levels, protein catabolism rates, and altered levels of micronutrients leading to uncontrolled oxidative stress, exhaustion of anaerobic commensals, and proliferation of pathobionts. Due to these alterations, kwashiorkor children present with profoundly impaired immune function, compromised intestinal barrier, and secondary micronutrient deficiencies. Kwashiorkor-induced alterations contribute to growth stunting and reduced efficacy of oral vaccines. SM is treated with antibiotics and ready-to-use therapeutic foods with variable efficacy. Kwashiorkor has been extensively investigated in gnotobiotic (Gn) mice and piglet models to understand its multiple immediate and long-term effects on children health. Due to numerous physiological and immunological similarities between pigs and humans, pig represents a highly relevant model to study kwashiorkor pathophysiology and immunology. Here we summarize the impact of kwashiorkor on children's health, immunity, and gut functions and review the relevant findings from human and animal studies. We also discuss the reciprocal interactions between PCD and rotavirus-a highly prevalent enteric childhood pathogen due to which pathogenesis and immunity are affected by childhood SM.

Undernutrition and short duration of breastfeeding association with child development: a population-based study

OBJECTIVE

To explore the relationship of undernutrition and the short duration of breastfeeding with child development of children 0-66 months of age residing in Ceará, Brazil.

METHODS

The authors of the present study utilized population-based data from children enrolled in the Study on Maternal and Child Health in Ceará, Brazil (PESMIC). Children's development was assessed with the Ages and Stages Questionnaire third version, validated in Brazil. Undernutrition was accessed through anthropometric measures obtained by trained staff. Breastfeeding information was obtained through the mothers' report and confirmed in the child's governmental booklet. The authors used logistic regressions adjusted for sample clusters used in PESMIC design in a theoretical model for known determinants of child development following the World Health Organization nurturing framework.

RESULTS

A total of 3,566 children were enrolled in the sixth PESMIC study and had their development assessed. The authors found that 8.2%, 3.0%, 2.1%, and 3.6% of children were stunted, underweight, or wasted, at the time of the interview, respectively. All studied factors were associated with a higher prevalence of child development impairment in at least one of the assessed domains. Underweight was the factor with the strongest effect, with an adjusted odds ratio (AOR) of 4,14 (2,26-7,58), p < 0.001. Breastfeeding for up to two months compared to more than six months (AOR 2,08 (1,38-3,12)) was also associated.

CONCLUSIONS

The authors found that undernutrition and short duration of breastfeeding are associated with development outcomes among Brazilian children. As a result, integrated nutritional programs may improve child development outcomes.

Microbiology and Epidemiology of Escherichia albertii—An Emerging Elusive Foodborne Pathogen

Escherichia albertii, a close relative of E. coli, is an emerging zoonotic foodborne pathogen associated with watery diarrhea mainly in children and immunocompromised individuals. E. albertii was initially classified as eae-positive Hafnia alvei, however, as more genetic and biochemical information became available it was reassigned to its current novel taxonomy. Its infections are common under conditions of poor hygiene with confirmed transmission via contaminated water and food, mainly poultry-based products. This pathogen has been isolated from various domestic and wild animals, with most isolates being derived from birds, implying that birds among other wild animals might act as its reservoir. Due to the absence of standardized isolation and identification protocols, E. albertii can be misidentified as other Enterobacteriaceae. Exploiting phenotypes such as its inability to ferment rhamnose and xylose and PCR assays targeting E. albertii-specific genes such as the cytolethal distending toxin and the DNA-binding transcriptional activator of cysteine biosynthesis encoding genes can be used to accurately identify this pathogen. Several gaps exist in our knowledge of E. albertii and need to be bridged. A deeper understanding of E. albertii epidemiology and physiology is required to allow the development of effective measures to control its transmission and infections. Overall, current data suggest that E. albertii might play a more significant role in global infectious diarrhea cases than previously assumed and is often overlooked or misidentified. Therefore, simple, and efficient diagnostic tools that cover E. albertii biodiversity are required for effective isolation and identification of this elusive agent of diarrhea.

Plasma Kynurenine to Tryptophan Ratio Is Not Associated with Undernutrition in Adults but Reduced after Nutrition Intervention: Results from a Community-Based Study in Bangladesh

Infections and persistent immunological activation are linked to increased kynurenine (KYN) and the KYN-to-Tryptophan (TRP) or KT ratio and may be critical factors in undernutrition. We sought to determine the association between the KT ratio and adult malnutrition, as well as investigate if nutritional supplementation had any influence on the decrease of the KT ratio. A total of 525 undernourished adults aged 18–45 years were recruited and provided a nutrition intervention for 60 feeding days. TRP and KYN concentrations were determined from plasma samples using LC-MS/MS. At baseline, the median (interquartile range (IQR)) TRP, KYN and KT ratios were 24.1 (17.6, 34.3) µmol/L, 0.76 (0.53, 1.18) µmol/L and 30.9 (24.5, 41.7), respectively. Following intervention, the median (IQR) KYN and KT ratios were significantly reduced to 0.713 (0.46, 1.12) µmol/L and 27.5 (21.3, 35.8). The KT ratio was found to be inversely linked with adult BMI (coefficient: −0.09; 95% CI: −0.18, 0.004; p-value = 0.06) but not statistically significant. Additionally, Plasma CRP was correlated positively, while LRP1 was inversely correlated with the KT ratio. Our data suggest that in Bangladeshi adults, the KT ratio is not related to the pathophysiology of malnutrition but correlated with inflammatory and anti-inflammatory biomarkers, and the ratio can be reduced by a nutrition intervention.

Association between Helicobacter pylori infection and growth outcomes in children: A meta-analysis

BACKGROUND

Multiple studies have reported the association between Helicobacter pylori (H. pylori) infection and children's growth. The results of these studies are controversial. Our meta-analysis aimed to evaluate the association between H. pylori infection and growth outcomes in children.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Library, as well as two Chinese databases, Wanfang, and CNKI from inception to September 2019. Odds ratios (ORs) and standardized mean differences (SMDs) with their 95% confidence interval (95% CI) were selected as the effect size. We assessed pooled data using a random-effects model. Subgroup and sensitivity analyses were conducted.

RESULTS

In total, 29 studies provided data from 9384 subjects. The meta-analysis results indicated a significant association of H. pylori infection with ponderal growth disorders (OR: 2.47; 95% CI: 1.13, 5.37; p = 0.02) and linear growth disorders (OR =1.76; 95% CI: 1.15, 2.69, p = 0.01). H. pylori infection has an adverse impact on children's height-for-age Z (HAZ) scores (SMD = -0.41; 95% CI: -0.69, -0.13; p < 0.01). Pooling SMDs by other outcomes (height, weight, BMI, weight-for-age and BMI-for-age Z scores, weight-for-age percentile scores, and linear and ponderal growth velocity with/without infection and eradication/non-eradication) all indicated no significant association.

CONCLUSION

The current evidence supports the hypothesis that H. pylori infection is associated with growth outcomes in children, mainly HAZ scores. Clinicians might consider H. pylori infection in investigating linear growth disorders in children.

Bayesian geostatistical modelling of stunting in Rwanda: risk factors and spatially explicit residual stunting burden

Background

Stunting remains a significant public health issue in Rwanda and its prevalence exhibits considerable geographical variation. We apply Bayesian geostatistical modelling to study the spatial pattern of stunting in children less than five years considering anthropometric, socioeconomic and demographic risk factors in Rwanda. In addition, we predict the spatial residuals effects to quantify the burden of stunting not accounted for by our geostatistical model.

Methods

We used the data from the 2015 Rwanda Demographic and Health Survey. We fitted two spatial logistic models with similar structures, only differentiated by the inclusion or exclusion of spatially structured random effects.

Results

The risk factors of stunting identified in the geostatistical model were being male (OR = 1.32, 95% CI: 1.16, 1.47), lower birthweight (kg) (OR = 0.96, 95% CI: 0.95, 0.97), non-exclusive breastfeeding (OR = 1.24, 95% CI: 1.04, 1.45), occurrence of diarrhoea in the last two weeks (OR = 1.18, 95% CI: 1.02, 1.37), a lower proportion of mothers with overweight (BMI ≥ 25) (OR = 0.82, 95% CI: 0.71, 0.95), a higher proportion of mothers with no or only primary education (OR = 1.14, 95% CI: 0.99, 1.36). Also, a higher probability of living in a house with poor flooring material (OR = 1.22, 95% CI: 1.06, 1.41), reliance on a non-improved water source (OR = 1.13, 95% CI: 1.00, 1.27), and a low wealth index were identified as risk factors of stunting. Mapping of the spatial residuals effects showed that, in particular, the Northern and Western regions, followed by the Southern region of Rwanda, still exhibit a higher risk of stunting even after accounting for all the covariates in the spatial model.

Conclusions

Further studies are needed to identify the still unknown spatially explicit factors associated with higher risk of stunting. Finally, given the spatial heterogeneity of stunting, interventions to reduce stunting should be geographically targeted.

Water, sanitation and hygiene interventions and the prevention and treatment of childhood acute malnutrition: A systematic review

Undernutrition is more prevalent among children living in unsanitary environments with inadequate water, sanitation and hygiene (WASH). Despite good evidence for the effect of WASH on multiple infectious diseases, evidence for the effect of WASH interventions on childhood undernutrition is less well established, particularly for acute malnutrition. To assess the effectiveness of WASH interventions in preventing and treating acute childhood malnutrition, we performed electronic searches to identify relevant studies published between 1 January 2000 and 13 May 2019. We included studies assessing the effect of WASH on prevention and treatment of acute malnutrition in children under 5 years of age. Data were extracted by two independent reviewers. We included 26 articles of 599 identified references with a total of 43,083 participants. Twenty-five studies reported on the effect of WASH on prevention, and two studies reported its effect on treatment of acute malnutrition. Current evidence does not show consistent associations of WASH conditions and interventions with prevention of acute malnutrition or with the improvement of its treatment outcomes. Only two high-quality randomized controlled trials (RCTs) demonstrated that improved water quality during severe acute malnutrition treatment improved recovery outcomes but did not prevent relapse. Many of the interventions consisted of a package of WASH services, making impossible to attribute the effect to one specific component. This highlights the need for high-quality, rigorous intervention studies assessing the effects of WASH interventions specifically designed to prevent acute malnutrition or improve its treatment.

Diarrhea Prevalence and Child Growth Faltering Are Associated with Subsequent Adverse Child Developmental Outcomes in Bangladesh (CHoBI7 Program)

Millions of young children annually are not meeting their developmental potential in low- and middle-income countries. Previous studies have shown that diarrheal diseases during early life are associated with subsequent malnutrition. This prospective cohort study of 576 children under 5 years was conducted in urban Dhaka, Bangladesh, to investigate the association between diarrhea prevalence, child growth, and child cognitive developmental outcomes. Height and weight were measured at baseline and a 12-month follow-up. Diarrhea prevalence was assessed through monthly surveillance visits. Developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem-solving, and combined developmental scores measured by the Extended Ages and Stages Questionnaire (EASQ) at the 12-month follow-up visit. To assess the association between diarrhea prevalence, child growth, and child cognitive developmental outcomes, linear regression models were fit using generalized estimating equations to account for clustering at the household level and to approximate 95% CIs. Diarrhea prevalence was negatively associated with change in height-for-age (HAZ) Z-scores from baseline to the 12-month follow-up (coefficient -0.85 [95% CI: -1.42, -0.28]). Diarrhea prevalence was a significant predictor of combined EASQ Z-scores with and without baseline stunting included in the model (-0.89 [95% CI: -1.67, -0.09] [baseline stunting included]) and (-0.88 [95% CI: -1.69, -0.07]). Change in HAZ from baseline to the 12-month follow-up was positively associated with follow-up combined EASQ Z-scores (0.28 [95% CI: 0.15, 0.42]). High diarrhea prevalence and linear growth faltering were associated with negative cognitive developmental outcomes among children residing in urban Dhaka, Bangladesh. Furthermore, high diarrhea prevalence was associated with negative child cognitive developmental outcomes with stunting included in the model, suggesting an effect of diarrhea on cognition independent of stunting.

Assessing the performance of clinical diagnostic models for dehydration among patients with cholera and undernutrition in Bangladesh

OBJECTIVE

Accurately assessing dehydration severity is a critical step in reducing mortality from diarrhoea, but is complicated by cholera and undernutrition. This study seeks to assess the accuracy of two clinical diagnostic models for dehydration among patients over five years with cholera and undernutrition and compare their respective performance to the World Health Organization (WHO) algorithm.

METHODS

In this secondary analysis of data collected from the NIRUDAK study, accuracy of the full and simplified NIRUDAK models for predicting severe and any dehydration was measured using the area under the Receiver Operator Characteristic curve (AUC) among patients over five with/without cholera and with/without wasting. Bootstrap with 1000 iterations was used to compare the m-index for each NIRUDAK model to that of the WHO algorithm.

RESULTS

A total of 2,139 and 2,108 patients were included in the nutrition and cholera subgroups respectively with an overall median age of 35 years (IQR = 42) and 49.6% female. All subgroups had acceptable discrimination in diagnosing severe or any dehydration (AUC > 0.60); though the full NIRUDAK model performed best among patients without cholera, with an AUC of 0.82 (95%CI:0.79, 0.85) and among patients without wasting, with an AUC of 0.79 (95%CI:0.76, 0.81). Compared with the WHO's algorithm, both the full and simplified NIRUDAK models performed significantly better in terms of their m-index (p < 0.001) for all comparisons, except for the simplified NIRUDAK model in the wasting group.

CONCLUSIONS

Both the full and simplified NIRUDAK models performed less well in patients over five years with cholera and/or wasting; however, both performed better than the WHO algorithm.

Linear Growth Faltering Is Associated with Subsequent Adverse Child Cognitive Developmental Outcomes in the Democratic Republic of the Congo (REDUCE Program)

Globally, 140 million children under 5 years of age are estimated to be stunted. Previous studies have found an association between stunting and poor cognitive outcomes. However, there is limited evidence of this association in sub-Saharan African settings, such as the Democratic Republic of the Congo (DRC). This prospective cohort study of 286 children under 5 years was conducted in rural DRC to investigate the association between diarrhea prevalence, child growth, and child cognitive developmental outcomes. Developmental outcomes were assessed by communication, fine motor, gross motor, personal social, problem-solving, and combined developmental scores measured by the Extended Ages and Stages Questionnaire (EASQ) at a 6-month follow-up visit. Height and weight were measured at baseline and a 6-month follow-up. Diarrhea prevalence was assessed through surveillance visits. Diarrhea prevalence was not associated with follow-up combined EASQ Z-scores at the 6-month follow-up (coefficient: -0.06 [95% CI: -0.29, 0.17]). Each additional standard deviation (SD) increase in height-for-age Z-scores from baseline to the 6-month follow-up increased combined EASQ Z-scores by 0.22 (95%: 0.14, -0.31) SDs. Each additional SD increase in weight-for-age Z-scores from baseline to the 6-month follow-up increased combined EASQ Z-scores by 0.21 (95%: 0.10, -0.32) SDs. Linear growth faltering and reduced weight gain were associated with reduced cognitive developmental outcomes among children residing in rural DRC. Interventions are urgently needed for this susceptible pediatric population to improve child growth and cognitive developmental outcomes.

Factors associated with diarrheal disease among children aged 1-5 years in a cholera epidemic in rural Haiti

Diarrheal illness is a major cause of morbidity and mortality among children in Haiti, and the impact of diarrheal illness was compounded by a cholera outbreak between 2010 and 2019. Our understanding of risk factors for diarrhea among children during this outbreak is limited. We conducted a secondary analysis of data collected as part of a cholera vaccine effectiveness study to identify factors associated with medically attended diarrhea among children in central Haiti from October of 2012 through November of 2016. We identified 47 children aged one to five years old who presented to medical clinics with acute, watery diarrhea, and 166 matched controls who did not have diarrhea, and we performed conditional logistic regression to identify factors associated with diarrhea. Discontinuing exclusive breastfeeding within one month of birth was associated with increased risk of diarrhea (RR 6.9, 95% CI 1.46–32.64), and diarrhea was inversely associated with reported history of supplementation with vitamin A (RR 0.05, 95% CI 0.004–0.56) and zinc (reported among 0% of cases vs. 17% of controls). Because of the concordance in supplementation patterns, it was not possible to attribute the association to vitamin A or zinc independently. While having a respondent who correctly identified ≥3 means of avoiding cholera was associated with reduced risk of diarrhea (RR 0.43, 95% CI 0.19–1.01), reported household sanitation practices and knowledge of cholera were not consistently associated with risk of diarrhea. These findings support ongoing efforts to reduce barriers to breastfeeding and promote pediatric supplementation with vitamin A and zinc in Haiti. Given the reduced efficacy of current oral cholera vaccines (OCV) among children, the results reinforce the importance of breastfeeding and micronutrient supplementation in preventing all-cause pediatric diarrheal illness generally and during cholera outbreaks.

Diarrheal diseases are leading causes of illness and death among children throughout the world, and children in Haiti were particularly impacted by diarrhea during the cholera outbreak that started in 2010. Between 2012 and 2016, data were collected as part of a case-control study of oral cholera vaccine (OCV) effectiveness in Haiti. We analyzed data from that study to identify factors associated with diarrheal illness, including cholera and non-cholera diarrhea, among children ages one through five years old. We found a direct association between longer duration of exclusive breastfeeding and supplementation with vitamin A and zinc and a reduced risk of diarrhea. These findings shed light on potentially important components of efforts to reduce pediatric diarrheal illness in Haiti generally, and to reduce pediatric diarrhea in the context of cholera outbreaks in Haiti and elsewhere.

Reframing anorexia nervosa as a metabo-psychiatric disorder

Anorexia nervosa (AN) is a serious and often fatal illness. Despite decades of research, investigators have failed to adequately advance our understanding of the biological aspects of AN that could inform the development of effective interventions. Genome-wide association studies are revealing the important role of metabolic factors in AN, and studies of the gastrointestinal tract are shedding light on disruptions in enteric microbial communities and anomalies in gut morphology. In this opinion piece, we review the state of the science through the lens of the clinical presentation of illness. We project how the integration of rigorous science in genomics and microbiology, in collaboration with experienced clinicians, has the potential to markedly enhance treatment outcome via precision interventions.

Histone H3 lysine 27 acetylation profile undergoes two global shifts in undernourished children and suggests altered one-carbon metabolism

BACKGROUND

Stunting is a condition in which a child does not reach their full growth potential due to chronic undernutrition. It arises during the first 2 years of a child's life and is associated with developmental deficiencies and life-long health problems. Current interventions provide some benefit, but new approaches to prevention and treatment grounded in a molecular understanding of stunting are needed. Epigenetic analyses are critical as they can provide insight into how signals from a poor environment lead to changes in cell function.

RESULTS

Here we profiled histone H3 acetylation on lysine 27 (H3K27ac) in peripheral blood mononuclear cells (PBMCs) of 18-week-old (n = 14) and 1-year-old children (n = 22) living in an urban slum in Dhaka, Bangladesh. We show that 18-week-old children destined to become stunted have elevated levels of H3K27ac overall, functional analysis of which indicates activation of the immune system and stress response pathways as a primary response to a poor environment with high pathogen load. Conversely, overt stunting at 1-year-of age is associated with globally reduced H3K27ac that is indicative of metabolic rewiring and downregulation of the immune system and DNA repair pathways that are likely secondary responses to chronic exposure to a poor environment with limited nutrients. Among processes altered in 1-year-old children, we identified one-carbon metabolism, the significance of which is supported by integrative analysis with results from histone H3 trimethylation on lysine 4 (H3K4me3). Together, these results suggest altered one-carbon metabolism in this population of stunted children.

CONCLUSIONS

The epigenomes of stunted children undergo two global changes in H3K27ac within their first year of life, which are associated with probable initial hyperactive immune responses followed by reduced metabolic capacity. Limitation of one-carbon metabolites may play a key role in the development of stunting. Trial registration ClinicalTrials.gov NCT01375647. Registered 17 June 2011, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01375647 .