Determinants of linear growth faltering among children with moderate-to-severe diarrhea in the Global Enteric Multicenter Study

Linear Growth During Treatment With a Simplified, Combined Protocol: Secondary Analyses of Severely Wasted Children 6-59 Months in the ComPAS Cluster Randomized Controlled Trial

A simplified, combined protocol treats children with moderate acute malnutrition (MAM), defined by mid-upper arm circumference (MUAC) of < 125 and ≥ 115 mm and no oedema, with 1 daily sachet of ready-to-use therapeutic food (RUTF) and those with severe acute malnutrition (SAM), defined by MUAC < 115 mm and/or oedema, with two daily sachets of RUTF. This protocol was previously shown to result in non-inferior recovery compared to standard treatment that used higher, weight-based RUTF dosing among children with SAM and ready-to-use supplementary food (RUSF) for MAM in a cluster-based randomised controlled trial in Kenya and South Sudan. We conducted a secondary analysis of this trial to compare linear growth among children admitted with MUAC < 115 mm. Linear and ponderal growth were calculated from admission to discharge and visualised using aggregate growth curves. HAZ change adjusted for admission characteristics was negative across the course of treatment but similar across arms [-0.21 ± 0.18 SE in the standard arm, -0.24 ± 0.18 SE in simplified; difference (95% confidence interval) 0.03 (-0.12, 0.18)]. The unadjusted mean ± SE linear growth velocity from admission to discharge was 1.8 ± 0.7 mm/week in the standard arm compared to 1.7 ± 0.7 mm/week in the simplified arm [difference = 0.09 (-0.36, 0.53)] and similar in adjusted analysis. MUAC and weight gain velocities were not significantly different by treatment arm. Reducing the RUTF dose prescribed to children during SAM treatment does not appear to affect linear growth or other growth velocities during treatment.

Predictive modelling of linear growth faltering among pediatric patients with Diarrhea in Rural Western Kenya: an explainable machine learning approach

INTRODUCTION

Stunting affects one-fifth of children globally with diarrhea accounting for an estimated 13.5% of stunting. Identifying risk factors for its precursor, linear growth faltering (LGF), is critical to designing interventions. Moreover, developing new predictive models for LGF using more recent data offers opportunity to enhance model accuracy, interpretability and capture new insights. We employed machine learning (ML) to derive and validate a predictive model for LGF among children enrolled with diarrhea in the Vaccine Impact on Diarrhea in Africa (VIDA) study and the Enterics for Global Heath (EFGH) - Shigella study in rural western Kenya.

METHODS

We used 7 diverse ML algorithms to retrospectively build prognostic models for the prediction of LGF (≥ 0.5 decrease in height/length for age z-score [HAZ]) among children 6-35 months. We used de-identified data from the VIDA study (n = 1,106) combined with synthetic data (n = 8,894) in model development, which entailed split-sampling and K-fold cross-validation with over-sampling technique, and data from EFGH-Shigella study (n = 655) for temporal validation. Potential predictors (n = 65) included demographic, household-level characteristics, illness history, anthropometric and clinical data were identified using boruta feature selection with an explanatory model analysis used to enhance interpretability.

RESULTS

The prevalence of LGF in the development and temporal validation cohorts was 187 (16.9%) and 147 (22.4%), respectively. Feature selection identified the following 6 variables used in model development, ranked by importance: age (16.6%), temperature (6.0%), respiratory rate (4.1%), SAM (3.4%), rotavirus vaccination (3.3%), and skin turgor (2.1%). While all models showed good prediction capability, the gradient boosting model achieved the best performance (area under the curve % [95% Confidence Interval]: 83.5 [81.6-85.4] and 65.6 [60.8-70.4]) on the development and temporal validation datasets, respectively.

CONCLUSION

Our findings accentuate the enduring relevance of established predictors of LGF whilst demonstrating the practical utility of ML algorithms for rapid identification of at-risk children.

Caregiver perceptions of complementary feeding in rural and urban Indonesia: A qualitative comparative study

OBJECTIVE

To explore caregivers' perspectives on complementary feeding in rural and urban areas of Central Java, Indonesia.

DESIGN

A qualitative comparative study using in-depth interviews. We applied thematic analysis to identify themes and subthemes and presented representative quotes.

SETTING

Rural and urban villages in Central Java Province, Indonesia.

PARTICIPANTS

46 mothers and grandmothers of 6- to 23-month-old children.

FINDINGS

We identified five themes: 1) timing of food introduction, 2) types of complementary foods, 3) meal preparations, 4) complementary food benefits, and 5) expectations toward complementary foods. While caregivers in urban areas had more favourable perceptions of complementary feeding, some misperceptions existed regarding complementary feeding in both areas. These misconceptions included the age of complementary food introduction, the delay in introducing animal-source foods, and the emphasis on any food the child preferred as long as they ate rather than on healthy food choices.

KEY CONCLUSIONS

There were similarities and differences in complementary feeding perspectives between caregivers in rural and urban areas. Therefore, policymakers and public health workers should design interventions to enhance complementary feeding practices by addressing the contextual issues in specific settings.

Association between chlorine-treated drinking water, the gut microbiome, and enteric pathogen burden in young children in Haiti: An observational study

OBJECTIVE

The effects of sanitation and hygiene interventions on the gut microbiome and enteric pathogen burden are not well understood. We measured the association between free chlorine residue (FCR) levels in drinking water, microbiome composition, and stool enteric pathogens in infants and young children in Haiti.

METHODS

FCR levels were measured in household drinking water and enteric pathogen burden was evaluated using multiplex RT-PCR of stool among 131 children from one month to five years of age living in Mirebalais, Haiti. Microbiome profiling was performed using metagenomic sequencing.

RESULTS

Most individuals lived in households with undetectable FCR measured in the drinking water (112/131, 86%). Detection of enteric pathogen DNA in stool was common and did not correlate with household water FCR. The infant microbiome in households with detectable FCR demonstrated reduced richness (fewer total number of species, P = 0.04 Kruskall-Wallis test) and less diversity by Inverse Simpson measures (P = 0.05) than households with undetectable FCR. Infants in households with a detectable FCR were more likely to have abundant Bifidobacterium. Using in vitro susceptibility testing, we found that some Bifidobacterium species were resistant to chlorine.

CONCLUSIONS

FCR in household drinking water did not correlate with enteric pathogen burden in our study.

Impact of integrated WASH and maternal and child health interventions on diarrhea disease prevalence in a resource-constrained setting in Kenya

BACKGROUND

Water, sanitation and hygiene (WASH) and child health interventions are proven simple and cost-effective strategies for preventing diarrhea and minimizing excess mortality. Individually, they are able to prevent diarrhea though sub-optimally, and their effectiveness when combined may be higher. This study examined the effect of integrated WASH and maternal and child health (MCH) interventions on prevalence of diarrhea, in a resource-limited setting in Kenya.

METHODS

A controlled intervention was implemented in Narok County. The interventions included WASH interventions integrated with promotion of MCH. A structured questionnaire was used to collect data on targeted indicators before and after the interventions. Data were analyzed using descriptive statistics and Chi-square to establish the impact of the interventions.

RESULTS

A total of 431and 424 households and 491 and 487 households in intervention and control sites, respectively, participated in the baseline and endline surveys. Following implementation of the interventions, prevalence of diarrhea decreased by 69.1% (95% CI: 49.6-87.1%) and 58.6% (95% CI: 26.6-82.4%) in the intervention and control site, respectively. Treatment of drinking water and animal husbandry practices were significantly associated with diarrhea post-interventions.

CONCLUSIONS

Integrating WASH interventions with other diarrhea control strategies and contextualizing them to meet site-specific needs may effectively prevent diarrhea.

Lactoferrin and lysozyme to promote nutritional, clinical and enteric recovery: a protocol for a factorial, blinded, placebo-controlled randomised trial among children with diarrhoea and malnutrition (the Boresha Afya trial)

INTRODUCTION

Children with moderate or severe wasting are at particularly high risk of recurrent or persistent diarrhoea, nutritional deterioration and death following a diarrhoeal episode. Lactoferrin and lysozyme are nutritional supplements that may reduce the risk of recurrent diarrhoeal episodes and accelerate nutritional recovery by treating or preventing underlying enteric infections and/or improving enteric function.

METHODS AND ANALYSIS

In this factorial, blinded, placebo-controlled randomised trial, we aim to determine the efficacy of lactoferrin and lysozyme supplementation in decreasing diarrhoea incidence and improving nutritional recovery in Kenyan children convalescing from comorbid diarrhoea and wasting. Six hundred children aged 6-24 months with mid-upper arm circumference <12.5 cm who are returning home after an outpatient visit or inpatient hospital stay for diarrhoea will be enrolled. Children will be randomised to 16 weeks of lactoferrin, lysozyme, a combination of the two, or placebo and followed for 24 weeks, with biweekly home visits by community health workers and clinic visits at 4, 10, 16 and 24 weeks. The primary analysis will compare the incidence of moderate-to-severe diarrhoea and time to nutritional recovery between each intervention arm and placebo. The trial will also test whether these interventions reduce enteric pathogen carriage, decrease enteric permeability and/or increase haemoglobin concentration in enrolled children. Finally, we will evaluate the acceptability, adherence and cost-effectiveness of lactoferrin and/or lysozyme.

ETHICS AND DISSEMINATION

The trial has been approved by the institutional review boards of the Kenya Medical Research Institute, the University of Washington, the Kenyan Pharmacy and Poisons Board, and the Kenyan National Commission on Science, Technology and Innovation. The results of this trial will be shared with local and international stakeholders and published in peer-reviewed journals, and the key findings will be presented at relevant conferences.

TRIAL REGISTRATION NUMBER

NCT05519254, PACTR202108480098476.

Azithromycin for Bacterial Watery Diarrhea: A Reanalysis of the AntiBiotics for Children With Severe Diarrhea (ABCD) Trial Incorporating Molecular Diagnostics

BACKGROUND

Bacterial pathogens cause substantial diarrhea morbidity and mortality among children living in endemic settings, yet antimicrobial treatment is only recommended for dysentery or suspected cholera.

METHODS

AntiBiotics for Children with severe Diarrhea was a 7-country, placebo-controlled, double-blind efficacy trial of azithromycin in children 2-23 months of age with watery diarrhea accompanied by dehydration or malnutrition. We tested fecal samples for enteric pathogens utilizing quantitative polymerase chain reaction to identify likely and possible bacterial etiologies and employed pathogen-specific cutoffs based on genomic target quantity in previous case-control diarrhea etiology studies to identify likely and possible bacterial etiologies.

RESULTS

Among 6692 children, the leading likely etiologies were rotavirus (21.1%), enterotoxigenic Escherichia coli encoding heat-stable toxin (13.3%), Shigella (12.6%), and Cryptosporidium (9.6%). More than one-quarter (1894 [28.3%]) had a likely and 1153 (17.3%) a possible bacterial etiology. Day 3 diarrhea was less common in those randomized to azithromycin versus placebo among children with a likely bacterial etiology (risk difference [RD]likely, -11.6 [95% confidence interval {CI}, -15.6 to -7.6]) and possible bacterial etiology (RDpossible, -8.7 [95% CI, -13.0 to -4.4]) but not in other children (RDunlikely, -0.3% [95% CI, -2.9% to 2.3%]). A similar association was observed for 90-day hospitalization or death (RDlikely, -3.1 [95% CI, -5.3 to -1.0]; RDpossible, -2.3 [95% CI, -4.5 to -.01]; RDunlikely, -0.6 [95% CI, -1.9 to .6]). The magnitude of risk differences was similar among specific likely bacterial etiologies, including Shigella.

CONCLUSIONS

Acute watery diarrhea confirmed or presumed to be of bacterial etiology may benefit from azithromycin treatment.

CLINICAL TRIALS REGISTRATION

NCT03130114.

Childhood growth during recovery from acute illness in Africa and South Asia: a secondary analysis of the childhood acute illness and nutrition (CHAIN) prospective cohort

Background

Growth faltering is well-recognized during acute childhood illness and growth acceleration during convalescence, with or without nutritional therapy, may occur. However, there are limited recent data on growth after hospitalization in low- and middle-income countries.

Methods

We evaluated growth following hospitalization among children aged 2-23 months in sub-Saharan Africa and South Asia. Between November 2016 and January 2019, children were recruited at hospital admission and classified as: not-wasted (NW), moderately-wasted (MW), severely-wasted (SW), or having nutritional oedema (NO). We describe earlier (discharge to 45-days) and later (45- to 180-days) changes in length-for-age [LAZ], weight-for-age [WAZ], mid-upper arm circumference [MUACZ], weight-for-length [WLZ] z-scores, and clinical, nutritional, and socioeconomic correlates.

Findings

We included 2472 children who survived to 180-days post-discharge: NW, 960 (39%); MW, 572 (23%); SW, 682 (28%); and NO, 258 (10%). During 180-days, LAZ decreased in NW (-0.27 [-0.36, -0.19]) and MW (-0.23 [-0.34, -0.11]). However, all groups increased WAZ (NW, 0.21 [95% CI: 0.11, 0.32]; MW, 0.57 [0.44, 0.71]; SW, 1.0 [0.88, 1.1] and NO, 1.3 [1.1, 1.5]) with greatest gains in the first 45-days. Of children underweight (<-2 WAZ) at discharge, 66% remained underweight at 180-days. Lower WAZ post-discharge was associated with age-inappropriate nutrition, adverse caregiver characteristics, small size at birth, severe or moderate anaemia, and chronic conditions, while lower LAZ was additionally associated with household-level exposures but not with chronic medical conditions.

Interpretation

Underweight and poor linear growth mostly persisted after an acute illness. Beyond short-term nutritional supplementation, improving linear growth post-discharge may require broader individual and family support.

Funding

Bill & Melinda Gates FoundationOPP1131320; National Institute for Health ResearchNIHR201813.

Critical research gaps in treating growth faltering in infants under 6 months: A systematic review and meta-analysis

In 2020, 149.2 million children worldwide under 5 years suffered from stunting, and 45.4 million experienced wasting. Many infants are born already stunted, while others are at high risk for growth faltering early after birth. Growth faltering is linked to transgenerational impacts of poverty and marginalization. Few interventions address growth faltering in infants under 6 months, despite a likely increasing prevalence due to the negative global economic impacts of the COVID-19 pandemic. Breastfeeding is a critical intervention to alleviate malnutrition and improve child health outcomes, but rarely receives adequate attention in growth faltering interventions. A systematic review and meta-analysis were undertaken to identify and evaluate interventions addressing growth faltering among infants under 6 months that employed supplemental milks. The review was carried out following guidelines from the USA National Academy of Medicine. A total of 10,405 references were identified, and after deduplication 7390 studies were screened for eligibility. Of these, 227 were assessed for full text eligibility and relevance. Two randomized controlled trials were ultimately included, which differed in inclusion criteria and methodology and had few shared outcomes. Both studies had small sample sizes, high attrition and high risk of bias. A Bangladeshi study (n = 153) found significantly higher rates of weight gain for F-100 and diluted F-100 (DF-100) compared with infant formula (IF), while a DRC trial (n = 146) did not find statistically significant differences in rate of weight gain for DF-100 compared with IF offered in the context of broader lactation and relactation support. The meta-analysis of rate of weight gain showed no statistical difference and some evidence of moderate heterogeneity. Few interventions address growth faltering among infants under 6 months. These studies have limited generalizability and have not comprehensively supported lactation. Greater investment is necessary to accelerate research that addresses growth faltering following a new research framework that calls for comprehensive lactation support.

Reassessing potential economic value and health impact of effective Shigella vaccines

The gram-negative bacterium Shigella is a leading cause of diarrheal morbidity and mortality in children in low- and middle-income countries. Several promising vaccine candidates are in late stages of clinical development against this increasingly antibiotic-resistant pathogen. However, considering the increasingly crowded and costly paediatric immunization schedule, and likely advent of other important new vaccines, it is unclear whether introduction of a Shigella vaccine would represent a high priority for international agencies or health ministries in low- and middle-income countries. To determine whether there is a compelling public health value proposition for a Shigella vaccine, we used the World Health Organization's Full Value of Vaccine Assessment analytic framework and formulated five broad scientific, policy, economic and commercial-related propositions regarding the development of a Shigella vaccine. We also explored the current regulatory, clinical, policy and commercial challenges to a Shigella-containing combination vaccine development and adoption. Through a series of literature reviews, expert consultations, social science field studies and model-based analyses, we addressed each of these propositions. As described in a series of separate publications that are synthesized here, we concluded that the economic and public health value of a Shigella vaccine may be greater than previously recognized, particularly if it is found to also be effective against less severe forms of diarrheal disease and childhood stunting. The decision by pharmaceutical companies to develop a standalone vaccine or a multipathogen combination will be a key factor in determining its relative prioritization by various stakeholders in low- and middle-income countries.

Predictive modeling for infectious diarrheal disease in pediatric populations: A systematic review

Introduction

Diarrhea is still a significant global public health problem. There are currently no systematic evaluation of the modeling areas and approaches to predict diarrheal illness outcomes. This paper reviews existing research efforts in predictive modeling of infectious diarrheal illness in pediatric populations.

Methods

We conducted a systematic review via a PubMed search for the period 1990-2021. A comprehensive search query was developed through an iterative process and literature on predictive modeling of diarrhea was retrieved. The following filters were applied to the search results: human subjects, English language, and children (birth to 18 years). We carried out a narrative synthesis of the included publications.

Results

Our literature search returned 2671 articles. After manual evaluation, 38 of these articles were included in this review. The most common research topic among the studies were disease forecasts 14 (36.8%), vaccine-related predictions 9 (23.7%), and disease/pathogen detection 5 (13.2%). Majority of these studies were published between 2011 and 2020, 28 (73.7%). The most common technique used in the modeling was machine learning 12 (31.6%) with various algorithms used for the prediction tasks. With change in the landscape of diarrheal etiology after rotavirus vaccine introduction, many open areas (disease forecasts, disease detection, and strain dynamics) remain for pathogen-specific predictive models among etiological agents that have emerged as important. Additionally, the outcomes of diarrheal illness remain under researched. We also observed lack of consistency in the reporting of results of prediction models despite the available guidelines highlighting the need for common data standards and adherence to guidelines on reporting of predictive models for biomedical research.

Conclusions

Our review identified knowledge gaps and opportunities in predictive modeling for diarrheal illness, and limitations in existing attempts whilst advancing some precursory thoughts on how to address them, aiming to invigorate future research efforts in this sphere.

When did the substantial loss of child linear growth occur?

BACKGROUND

Epidemiological studies show that the height-for-age Z-scores (HAZ) falter dramatically shortly after birth until the end of the first two years. Understanding these changes in linear growth in the first two years can help us understand the critical period of child linear growth and propose interventions.

OBJECTIVES

This study objectives were to describe the pattern of linear growth faltering and analyze the changes in length-for-age Z-scores (LAZs) throughout the first two years based on birthweight and length status.

METHODS

This study analyzed 408 children, participants in Longitudinal Study on Child Growth and Development in Bogor, Indonesia. The linear growth pattern was described based on birthweight and length status. Birthweight and length status was categorized into normal and Small for Gestational Age (SGA). Changes in LAZs (Δ LAZs) in 0-6 months, 6-12 months, and 12-23 months were calculated. General Linear Model Univariate analysis was conducted to analyze the difference of Δ LAZ between SGA and normal children.

RESULTS

Though full-term SGA children have significantly higher linear growth velocity during the first 6 months of the infancy period, full-term SGA children could not catch up with the attained growth/height of normal children throughout the first two years. Thus, full-term SGA children ended up with a higher prevalence of stunted. Both in SGA and normal children, the substantial loss of LAZ occurred between 0-6 months.

CONCLUSION

The finding in this study showed that the first 1000 days of life is still the best period in stunting prevention; however, the stunting prevention program should start earlier, focusing on the first 500 days of life, and potentially the prenatal period.

Shigella and childhood stunting: Evidence, gaps, and future research directions

Early childhood growth deficits have been shown to have lifelong health and economic impacts, yet their connection to one of their underlying causes, diarrheal diseases, has remained difficult to characterize. Identifying the processes and mechanisms that underlie this link has remained a challenge due to the complexity of the relationship and limitations in access to more advanced laboratory methods. In recent years, however, several large-scale, multisite studies have extensively investigated and reported the prevalence, etiology, and impacts of diarrheal diseases in children under 5 years (CU5) in low- to middle-income countries (LMICs). These studies, in combination with several single-site studies, have applied more advanced laboratory methods to uncover the etiology, true prevalence, infection mechanisms, and inflammation biomarkers of diarrheal disease. Of the multiple pathogens that have been shown to be strongly associated with diarrheal disease in CU5, Shigella is one of the more prevalent and impactful of these pathogens. In this narrative review, we highlight key insights from these studies and identify knowledge gaps and directions for future research. According to these studies, Shigella is most commonly detected in toddlers and young children; however, it can cause more severe disease and has a greater impact on linear growth for infants. Shigella often has a stronger relationship to linear growth faltering (LGF) than other enteropathogens, with higher Shigella loads resulting in greater growth deficits. Future studies should employ more Shigella-specific molecular assays and identify diarrheal etiologies using standardized diagnostics to improve child anthropometric and Shigella surveillance. Also, they should focus on uncovering the mechanisms of the relationship underlying Shigella and growth faltering to better characterize the role of asymptomatic infections and intestinal inflammation in this relationship.

Social and Environmental Determinants of Diarrheal Diseases among Children under Five Years in Epworth Township, Harare

Children five years or younger in low- and middle-income countries (LMICs) are severely affected by diarrheal disease, especially in the sub-Saharan region. Hence, this study aimed at determining the prevalence and determinants of diarrhoea disease among children under 5 years in Epworth Township, Zimbabwe. A descriptive cross-sectional study was conducted at a local clinic in Epworth Township, Harare. A convenience sampling strategy was used to recruit study participants for participation, and 386 children were enrolled in the study. The majority were male children (n = 229; 59.3%), whereas there were more female caregivers (n = 370; 95.9%) than male caregivers (n = 16; 4.1%). The prevalence of diarrhoea disease in the study was 25.1%. The determinants associated with diarrhoea were being partially vaccinated (AOR 2.38, CI: 95% 2.80-8.22), collecting water more than 1 kilometre from a household (AOR 4.55; CI: 95% 2.10-9.85), and using untreated water (AOR 6.22; CI: 95% 2.13-18.20). The age of the caregiver (being older than 21) and using a clean water container (AOR 0.05; CI: 95% 0.02-0.13) were protective factors. Provision of primary health care, especially the prevention of a disease through immunization and rendering environmental health services, could reduce the prevalence of diarrhoea in disadvantaged townships.

Derivation and external validation of clinical prediction rules identifying children at risk of linear growth faltering

Background

Nearly 150 million children under-5 years of age were stunted in 2020. We aimed to develop a clinical prediction rule (CPR) to identify children likely to experience additional stunting following acute diarrhea, to enable targeted approaches to prevent this irreversible outcome.

Methods

We used clinical and demographic data from the Global Enteric Multicenter Study (GEMS) to build predictive models of linear growth faltering (decrease of ≥0.5 or ≥1.0 in height-for-age z-score [HAZ] at 60-day follow-up) in children ≤59 months presenting with moderate-to-severe diarrhea, and community controls, in Africa and Asia. We screened variables using random forests, and assessed predictive performance with random forest regression and logistic regression using fivefold cross-validation. We used the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study to (1) re-derive, and (2) externally validate our GEMS-derived CPR.

Results

Of 7639 children in GEMS, 1744 (22.8%) experienced severe growth faltering (≥0.5 decrease in HAZ). In MAL-ED, we analyzed 5683 diarrhea episodes from 1322 children, of which 961 (16.9%) episodes experienced severe growth faltering. Top predictors of growth faltering in GEMS were: age, HAZ at enrollment, respiratory rate, temperature, and number of people living in the household. The maximum area under the curve (AUC) was 0.75 (95% confidence interval [CI]: 0.75, 0.75) with 20 predictors, while 2 predictors yielded an AUC of 0.71 (95% CI: 0.71, 0.72). Results were similar in the MAL-ED re-derivation. A 2-variable CPR derived from children 0-23 months in GEMS had an AUC = 0.63 (95% CI: 0.62, 0.65), and AUC = 0.68 (95% CI: 0.63, 0.74) when externally validated in MAL-ED.

Conclusions

Our findings indicate that use of prediction rules could help identify children at risk of poor outcomes after an episode of diarrheal illness. They may also be generalizable to all children, regardless of diarrhea status.

Funding

This work was supported by the National Institutes of Health under Ruth L. Kirschstein National Research Service Award NIH T32AI055434 and by the National Institute of Allergy and Infectious Diseases (R01AI135114).

Association between asymptomatic infections and linear growth in 18-24-month-old Malawian children

Inadequate diet and frequent symptomatic infections are considered major causes of growth stunting in low-income countries, but interventions targeting these risk factors have achieved limited success. Asymptomatic infections can restrict growth, but little is known about their role in global stunting prevalence. We investigated factors related to length-for-age Z-score (LAZ) at 24 months by constructing an interconnected network of various infections, biomarkers of inflammation (as assessed by alpha-1-acid glycoprotein [AGP]), and growth (insulin-like growth factor 1 [IGF-1] and collagen X biomarker [CXM]) at 18 months, as well as other children, maternal, and household level factors. Among 604 children, there was a continuous decline in mean LAZ and increased mean length deficit from birth to 24 months. At 18 months of age, the percentage of asymptomatic children who carried each pathogen was: 84.5% enterovirus, 15.5% parechovirus, 7.7% norovirus, 4.6% rhinovirus, 0.6% rotavirus, 69.6% Campylobacter, 53.8% Giardia lamblia, 11.9% malaria parasites, 10.2% Shigella, and 2.7% Cryptosporidium. The mean plasma IGF-1 concentration was 12.5 ng/ml and 68% of the children had systemic inflammation (plasma AGP concentration >1 g/L). Shigella infection was associated with lower LAZ at 24 months through both direct and indirect pathways, whereas enterovirus, norovirus, Campylobacter, Cryptosporidium, and malaria infections were associated with lower LAZ at 24 months indirectly, predominantly through increased systemic inflammation and reduced plasma IGF-1 and CXM concentration at 18 months.

Could a Shigella vaccine impact long-term health outcomes?: Summary report of an expert meeting to inform a Shigella vaccine public health value proposition, March 24 and 29, 2021

Shigellosis is a leading cause of diarrhea and dysentery in young children from low to middle-income countries and adults experiencing traveler’s diarrhea worldwide. In addition to acute illness, infection by Shigella bacteria is associated with stunted growth among children, which has been linked to detrimental long-term health, developmental, and economic outcomes. On March 24 and 29, 2021, PATH convened an expert panel to discuss the potential impact of Shigella vaccines on these long-term outcomes. Based on current empirical evidence, this discussion focused on whether Shigella vaccines could potentially alleviate the long-term burden associated with Shigella infections. Also, the experts provided recommendations about how to best model the burden, health and vaccine impact, and economic consequences of Shigella infections. This international multidisciplinary panel included 13 scientists, physicians, and economists from multiple relevant specialties.

According to the panel, while the relationship between Shigella infections and childhood growth deficits is complex, this relationship likely exists. Vaccine probe studies are the crucial next step to determine whether vaccination could ameliorate Shigella infection-related long-term impacts. Infants should be vaccinated during their first year of life to maximize their protection from severe acute health outcomes and ideally reduce stunting risk and subsequent negative long-term developmental and health impacts. With vaccine schedule crowding, targeted or combination vaccination approaches would likely increase vaccine uptake in high-burden areas. Shigella impact and economic assessment models should include a wider range of linear growth outcomes. Also, these models should produce a spectrum of results—ones addressing immediate benefits for usual health care decision-makers and others that include broader health impacts, providing a more comprehensive picture of vaccination benefits. While many of the underlying mechanisms of this relationship need better characterization, the remaining gaps can be best addressed by collecting data post-vaccine introduction or through large trials.

Development of a diarrhoea severity scoring scale in a passive health facility-based surveillance system

Background

Diarrhoeal disease remains a leading cause of death among children mostly in low and middle-income countries. Factors contributing to disease severity are complex and there is currently no consensus on a scoring tool for use in community-based studies.

Methods

Data were collected during a passive surveillance system in an outpatient health facility in Lusaka, Zambia from March 2019 to July 2019. Diarrhea episodes were assessed for severity using an in-house severity scoring tool (CIDRZ) and previously published scores (Vesikari, Clark, CODA, and DHAKA). The CIDRZ score was constructed using fieldworker-reported clinical signs and exploratory factor analysis. We used precision-recall curves measuring severe diarrhoea (i.e., requiring intravenous rehydration or referred for hospital admission) to determine the best performing scores. Then, we used Cronbach’s alpha to assess the scale’s internal consistency. Finally, we used Cohen’s kappa to assess agreement between the scores.

Results

Of 110 diarrhea episodes, 3 (3%) required intravenous rehydration or were referred for hospital admission. The precision-recall area under the curve of each score as a predictor of severe diarrhoea requiring intravenous rehydration or hospital admission was 0.26 for Vesikari, 0.18 for CODA, 0.24 for Clark, 0.59 for DHAKA, and 0.59 for CIDRZ. The CIDRZ scale had substantial reliability and performed similarly to the DHAKA score.

Conclusions

Diarrhoea severity scores focused on characteristics specific to dehydration status may better predict severe diarrhea among children in Lusaka. Aetiology-specific scoring tools may not be appropriate for use in community healthcare settings. Validation studies for the CIDRZ score in diverse settings and with larger sample sizes are warranted.

Protocol for a systematic review on routine use of antibiotics for infants less than 6 months of age with growth failure/faltering

INTRODUCTION

Antibiotics have been used as an adjunct in treating children with severe acute malnutrition 6-59 months of age; however, the data for infants less than 6 months are scarce. The WHO recently started guideline development for preventing and treating wasting, including growth failure/faltering in infants less than 6 months. This systematic review commissioned by WHO aims to synthesise evidence from current literature on the effectiveness of antibiotics for infants less than 6 months of age with growth failure/faltering.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis for studies that assessed the effect of antibiotics in the treatment of infants with growth faltering. We will search multiple electronic databases. We will include randomised control trials and non-randomised studies with a control arm. The study population is infants less than 6 months of age with growth failure. The intervention group will be infants who received no antibiotics or antibiotics other than recommended in 2013 guidelines by WHO to treat severe acute malnutrition in children. The comparison group will be infants who received antibiotics according to the 2013 guideline by WHO. We will consider the following outcomes: mortality, clinical deterioration, antimicrobial resistance, recovery from comorbidity, adverse events, markers of intestinal inflammation, markers of systemic inflammation, hospital-acquired infections, non-response. We will use the meta-analysis to pool the studies where applicable. We will use the Grading of Recommendations Assessment, Development, and Evaluation approach to reporting the overall evidence quality for an outcome.

ETHICS AND DISSEMINATION

This is a systematic review and will not involve contact with a human subject. The findings of this review will be published in a peer-review journal and will guide the WHO's recommendation for the use of antibiotics in infants less than 6 months of age with growth failure.

PROSPERO REGISTRATION NUMBER

CRD42021277073.

Examination of the Cameroon DHS data to investigate how water access and sanitation services are related to diarrhea and nutrition among infants and toddlers in rural households

Undernutrition among children is a significant issue in rural areas in Cameroon, with diarrhea being one of the major contributing risk factors. To gain a better understanding of the risk factors of diarrhea, the main objective of this epidemiological study was to examine associations between water access and sanitation service with diarrhea, diet diversity, and anemia among infants and toddlers in rural households in Cameroon. The study involved household- and individual-level data of 2,129 rural-dwelling infants and toddlers from the Demographic and Health Survey database. About one-third of infants and toddlers were experiencing diarrhea, with higher odds among those who lived in households with limited water service (p = 0.028). The odds of having diarrhea were 50% higher among infants and toddlers when households did not have sanitation facilities (p = 0.007). The lack of improved water and sanitation was also associated with a low intake of various food groups among older infants and toddlers. The prevalence of anemia was high, but no significant differences were seen by water and sanitation services. The achievement of SDG #6 will help address undernutrition and achieve other SDGs, including improving health and wellbeing.

Combating Childhood Infections in LMICs: evaluating the contribution of Big Data Big data, biomarkers and proteomics: informing childhood diarrhoeal disease management in Low- and Middle-Income Countries

Despite efforts to reduce the global burden of childhood diarrhoea, 50% of all cases globally occur in children under five years in Low–Income and Middle- Income Countries (LMICs) and knowledge gaps remain regarding the aetiological diagnosis, introduction of diarrhoeal vaccines, and the role of environmental enteric dysfunction and severe acute malnutrition. Biomarkers may assist in understanding disease processes, from diagnostics, to management of childhood diarrhoea and the sequelae to vaccine development. Proteomics has the potential to assist in the identification of new biomarkers to understand the processes in the development of childhood diarrhoea and to aid in developing new vaccines. Centralised repositories that enable mining of large data sets to better characterise risk factors, the proteome of both the patient and the different diarrhoeal pathogens, and the environment, could inform patient management and vaccine development, providing a systems biological approach to address the burden of childhood diarrhoea in LMICs.

Metagenomic analysis of gut microbiome and resistome of diarrheal fecal samples from Kolkata, India, reveals the core and variable microbiota including signatures of microbial dark matter

BACKGROUND

Metagenomic analysis of the gut microbiome and resistome is instrumental for understanding the dynamics of diarrheal pathogenesis and antimicrobial resistance transmission (AMR). Metagenomic sequencing of 20 diarrheal fecal samples from Kolkata was conducted to understand the core and variable gut microbiota. Five of these samples were used for resistome analysis. The pilot study was conducted to determine a microbiota signature and the source of antimicrobial resistance genes (ARGs) in the diarrheal gut.

RESULTS

16S rRNA amplicon sequencing was performed using Illumina MiSeq platform and analysed using the MGnify pipeline. The Genome Taxonomy Database (GTDB-Tk) was used for bacterial taxonomic identification. Diarrheal etiology was determined by culture method. Phylum Firmicutes, Bacteroidetes, Proteobacteria and Actinobacteria were consistently present in 20 samples. Firmicutes was the most abundant phylum in 11 samples. The Bacteroidetes/Firmicutes ratio was less than 1 in 18 samples. 584 genera were observed. 18 of these were present in all the 20 samples. Proteobacteria was the dominant phylum in 6 samples associated with Vibrio cholerae infection. Conservation of operational taxonomic units (OTUs) among all the samples indicated the existence of a core microbiome. Asymptomatic carriage of pathogens like Vibrio cholerae and Helicobacter pylori was found. Signature of Candidate phyla or "microbial dark matter" occurred. Significant correlation of relative abundance of bacterial families of commensals and pathogens were found. Whole-genome sequencing (WGS) on Illumina MiSeq system and assembly of raw reads using metaSPAdes v3.9.1 was performed to study the resistome of 5 samples. ABRicate was used to assign ARG function. 491 resistance determinants were identified. In 80% of the samples tetracycline resistance was the most abundant resistance determinant. High abundance of ARGs against β-lactams, aminoglycosides, quinolones and macrolides was found. Eschericia sp. was the major contributor of ARGs.

CONCLUSIONS

This is the first comparative study of the gut microbiome associated with different diarrheal pathogens. It presents the first catalogue of different bacterial taxa representing the core and variable microbiome in acute diarrheal patients. The study helped to define a trend in the gut microbiota signature associated with diarrhea and revealed which ARGs are abundantly present and the metagenome-assembled genomes (MAGs) contributing to AMR.

Tackling the triple threats of childhood malnutrition

The term 'double burden of malnutrition' is usually interpreted in terms of the physical status of children: stunted and wasted children on the one hand and overweight/obese children on the other. There is a third category of malnutrition that can occur at either end of the anthropometric spectrum or, indeed, in children whose physical size may be close to ideal. This third type is most commonly articulated with the phrase 'hidden hunger' and is often illustrated by micronutrient deficiencies; thus, we refer to it here as 'undernutrition'. As understanding of such issues advances, we realise that there is a myriad of factors that may be influencing a child's road to nutritional health. In this BMC Medicine article collection we consider these influences and the impact they have, such as: the state of the child's environment; the effect this has on their risk of, and responses to, infection and on their gut; the consequences of poor nutrition on cognition and brain development; the key drivers of the obesity epidemic across the globe; and how undernourishment can affect a child's body composition. This collection showcases recent advances in the field, but likewise highlights ongoing challenges in the battle to achieve adequate nutrition for children across the globe.