Does childhood diarrhea influence cognition beyond the diarrhea-stunting pathway?

Modeling the Risk Factors of Undernutrition among Children below Five Years of Age in Uganda Using Generalized Structural Equation Models

INTRODUCTION

The prevalence of undernutrition among children below five years of age, in Uganda and the world over, remains very high. About 45% of all global deaths among children below five years of age are attributed to undernutrition. A number of studies using different statistical approaches affirm this effect, yet some factors indicate the influence of other factors within the system. This study, therefore, uses a method that demonstrates how different variables feed into each other.

AIM

The aim of this study was to establish the major factors associated with an increased likelihood of undernutrition and the paths showing how these risk factors influence undernutrition.

METHODS

Data from the Uganda Demographic and Health Survey (UDHS, 2016) were used for this study. A sample of 4530 children, whose age, height, and weight measurements were recorded, was considered for this study. Additionally, the study used generalized structural equation models to identify the multifaceted natures and paths of the risk factors that influence undernutrition among children below five years of age. The study relied on the UNICEF 2020 conceptual framework to identify and analyze the direct and indirect effects of these risk factors of undernutrition.

RESULTS

From the perspective of a male child, having a perceived small size at birth, a low birth weight, being breastfed for less than 6 months, having no formal education from mothers, limited income-generating opportunities, a low wealth status, and notable episodes of diarrhea were among the key factors associated with an increased likelihood of undernutrition. The identified paths were as follows: (i) Having no education, as this was associated with limited working opportunities and a low income, which increases the likelihood of low household wealth status, hence increasing the chances of undernutrition. (ii) Exposure to a rural setting was associated with an increased likelihood of undernutrition through association with poor and or low employment levels within the rural areas. (iii) A shorter duration of breastfeeding was associated with children in urban areas, resulting in an increased likelihood of undernutrition. (iv) Children aged between 6 and 47 months had a higher likelihood of undernutrition.

CONCLUSIONS

An approach that addresses and recognizes all these factors at different levels, along the established paths, should be implemented to effectively reduce undernutrition among children below five years of age.

Associations between human milk oligosaccharides and infant growth in a Bangladeshi mother-infant cohort

BACKGROUND

We aimed to estimate associations between human milk oligosaccharides (HMOs) and infant growth (length-for-age (LAZ) and weight-for-length (WLZ) z-scores) at 12 months postnatal age.

METHODS

In this secondary analysis of data from a maternal vitamin D trial in Dhaka, Bangladesh (N = 192), absolute concentrations of HMOs were measured in 13 ± 1 week(s) postpartum milk samples, infant anthropometric measurements were obtained soon after birth and at 12 months postpartum, and infant feeding was classified during 6 months postpartum. Associations between individual HMOs or HMO groups and LAZ or WLZ were estimated by multivariable linear regression adjusting for infant feeding pattern, maternal secretor status, and other potential confounders.

RESULTS

The concentrations of 6'sialyllactose, lacto-N-neotetraose, and the non-fucosylated non-sialylated HMOs were inversely associated with LAZ at 12 months of age, whereas the fucosylated non-sialylated HMO concentration was positively associated with LAZ at 12 months. These associations were robust in analyses restricted to infants who were primarily exclusively/predominantly fed human milk during the first 3 (or 6) months.

CONCLUSIONS

Since HMOs are both positively and negatively associated with postnatal growth, there is a need for randomized trials to estimate the causal benefits and risks of exogenously administered HMOs on infant growth and other health outcomes.

IMPACT

6'sialyllactose, lacto-N-neotetraose, and the non-fucosylated non-sialylated human milk oligosaccharides (HMOs) were inversely associated with length-for-age z-scores (LAZ) at 12 months, whereas the fucosylated non-sialylated HMO concentration was positively associated with LAZ at 12 months among Bangladeshi infants. Associations between individual and grouped HMOs with infant length growth at 12 months were as strong or stronger in analyses restricted to infants who were exclusively or predominantly fed human milk up to 3 (or 6) months. Randomized trials are needed to characterize the effects of specific HMOs on infant growth, particularly in countries where postnatal linear growth faltering is common.

Cumulative Febrile, Respiratory, and Gastrointestinal Illness Among Infants in Rural Guatemala and Association With Neurodevelopmental and Growth Outcomes

BACKGROUND

Infectious disease exposures in early life are increasingly recognized as a risk factor for poor subsequent growth and neurodevelopment. We aimed to evaluate the association between cumulative illness with neurodevelopment and growth outcomes in a birth cohort of Guatemalan infants.

METHODS

From June 2017 to July 2018, infants 0-3 months of age living in a resource-limited region of rural southwest Guatemala were enrolled and underwent weekly at-home surveillance for caregiver-reported cough, fever, and vomiting/diarrhea. They also underwent anthropometric assessments and neurodevelopmental testing with the Mullen Scales of Early Learning (MSEL) at enrollment, 6 months, and 1 year.

RESULTS

Of 499 enrolled infants, 430 (86.2%) completed all study procedures and were included in the analysis. At 12-15 months of age, 140 (32.6%) infants had stunting (length-for-age Z [LAZ] score < -2 SD) and 72 (16.7%) had microcephaly (occipital-frontal circumference [OFC] < -2 SD). In multivariable analysis, greater cumulative instances of reported cough illness (beta = -0.08/illness-week, P = 0.06) and febrile illness (beta = -0.36/illness-week, P < 0.001) were marginally or significantly associated with lower MSEL Early Learning Composite (ELC) Score at 12-15 months, respectively; there was no association with any illness (cough, fever, and/or vomiting/diarrhea; P = 0.27) or with cumulative instances of diarrheal/vomiting illness alone ( P = 0.66). No association was shown between cumulative instances of illness and stunting or microcephaly at 12-15 months.

CONCLUSIONS

These findings highlight the negative cumulative consequences of frequent febrile and respiratory illness on neurodevelopment during infancy. Future studies should explore pathogen-specific illnesses, host response associated with these syndromic illnesses, and their association with neurodevelopment.

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.

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.

Supplementation With Fish Oil in Pregnancy Reduces Gastroenteritis in Early Childhood

BACKGROUND

We hypothesized that insufficient intake of fish oil-derived omega-3 long-chain polyunsaturated fatty acids (n-3 LCPUFAs) during pregnancy is a contributing factor to gastroenteritis in early childhood. We examined the effect of n-3 LCPUFA supplementation on gastroenteritis symptoms in the offspring's first 3 years of life.

METHODS

This was a double-blinded, randomized controlled trial whereby 736 mothers were administered n-3 LCPUFA or control from pregnancy week 24 until 1 week after birth. We measured the number of days with gastroenteritis, number of episodes with gastroenteritis, and the risk of having a gastroenteritis episode in the first 3 years of life.

RESULTS

A median reduction of 2.5 days with gastroenteritis (P = .018) was shown, corresponding to a 14% reduction in the n-3 LCPUFA group compared with controls in the first 3 years of life (P = .037). A reduction in the number of gastroenteritis episodes (P = .027) and a reduced risk of having an episode (hazard ratio, 0.80 [95% confidence interval, .66-.97]; P = .023) were also shown.

CONCLUSIONS

Fish oil supplementation from the 24th week of pregnancy led to a reduction in the number of days and episodes with gastroenteritis symptoms in the first 3 years of life. The findings suggest n-3 LCPUFA supplementation as a preventive measure against gastrointestinal infections in early childhood.

CLINICAL TRIALS REGISTRATION

NCT00798226.

Protocol for a parallel group, two-arm, superiority cluster randomised trial to evaluate a community-level complementary-food safety and hygiene and nutrition intervention in Mali: the MaaCiwara study (version 1.3; 10 November 2022)

BACKGROUND

Diarrhoeal disease remains a significant cause of morbidity and mortality among the under-fives in many low- and middle-income countries. Changes to food safety practices and feeding methods around the weaning period, alongside improved nutrition, may significantly reduce the risk of disease and improve development for infants. We describe a protocol for a cluster randomised trial to evaluate the effectiveness of a multi-faceted community-based educational intervention that aims to improve food safety and hygiene behaviours and enhance child nutrition.

METHODS

We describe a mixed-methods, parallel group, two-arm, superiority cluster randomised controlled trial with baseline measures. One hundred twenty clusters comprising small urban and rural communities will be recruited in equal numbers and randomly allocated in a 1:1 ratio to either treatment or control arms. The community intervention will be focussed around an ideal mother concept involving all community members during campaign days with dramatic arts and pledging, and follow-up home visits. Participants will be mother-child dyads (27 per cluster period) with children aged 6 to 36 months. Data collection will comprise a day of observation and interviews with each participating mother-child pair and will take place at baseline and 4 and 15 months post-intervention. The primary analysis will estimate the effectiveness of the intervention on changes to complementary-food safety and preparation behaviours, food and water contamination, and diarrhoea. Secondary outcomes include maternal autonomy, enteric infection, nutrition, child anthropometry, and development scores. A additional structural equation analysis will be conducted to examine the causal relationships between the different outcomes. Qualitative and health economic analyses including process evaluation will be done.

CONCLUSIONS

The trial will provide evidence on the effectiveness of community-based behavioural change interventions designed to reduce the burden of diarrhoeal disease in the under-fives and how effectiveness varies across different contexts.

TRIAL REGISTRATION

ISRCTN14390796. Registration date December 13, 2021.

Associations of early-life exposures and socioeconomic status with cognitive development at preadolescence

BACKGROUND

The long-term relations of socioeconomic status (SES) and early-life exposures with cognitive development at preadolescence are not fully understood, especially in low SES populations. We examined associations of SES and early-life exposures including feeding practices, physical growth and infections with cognitive development among preadolescents from underprivileged communities.

METHODS

A prospective study was conducted among 146 healthy children from two relatively low SES Arab villages in Israel, who were recruited at age 1-9 weeks and followed until age 18 months. Information was obtained on their feeding practices, health status and growth indicators. Cognitive development at age 10-12 years was assessed using the Wechsler Intelligence Scale, including the full-scale intelligence quotient (FSIQ) and scores of four cognitive domains. Multiple linear regression models were performed.

RESULTS

Nearly all the children (98%) were breastfed in infancy. Bivariate correlations were found of SES, growth indices and rates of diarrheal and respiratory illnesses in infancy, but not of feeding practices, with cognitive scores. In multivariable models, SES was positively (p < 0.001) associated with all the cognitive domains (beta coefficient ranges 4.3 to 8.2). Birthweight was positively associated with FSIQ (p = 0.039) and the perceptual reasoning index (p = 0.002). Weight for age Z score at age 10-14 months was positively associated with the verbal comprehension index (p = 0.003). The rate of respiratory illnesses was negatively associated with the perceptual reasoning index (p = 0.05).

CONCLUSION

SES is strongly associated with cognitive development even in relatively low SES communities. Birthweight, weight indicators and respiratory illness in infancy might affect cognitive development through preadolescence.

Impact of Shigella infections and inflammation early in life on child growth and school-aged cognitive outcomes: Findings from three birth cohorts over eight years

Background

Shigella infections cause inflammation, which has been hypothesized to mediate the associations between Shigella and child development outcomes among children in low-resource settings. We aimed to assess whether early life inflammation and Shigella infections affect school-aged growth and cognitive outcomes from 6–8 years of age.

Methodology/principal findings

We conducted follow-up assessments of anthropometry, reasoning skills, and verbal fluency in 451 children at 6–8 years of age in the Brazil, Tanzania, and South Africa sites of MAL-ED, a longitudinal birth cohort study. We estimated the associations between Shigella burden and inflammation with linear growth at 2, 5, and 6–8 years of age, and with the cognitive test scores using linear regression and adjusting for potential confounding variables. We also assessed whether inflammation mediated the associations between Shigella and school-aged outcomes using a regression-based approach to mediation analysis. A high prevalence of Shigella was associated with a 0.32 (95% CI: 0.08, 0.56) z-score lower height-for-age z-score (HAZ) at 6–8 years compared to a low prevalence of Shigella. Intestinal inflammation had a smaller association with HAZ at 6–8 years. Shigella burden had small and consistently negative associations with cognitive outcomes in Brazil and Tanzania, but not South Africa, and the estimates were not statistically significant. Systemic inflammation was strongly associated with lower verbal fluency scores in Brazil (semantic fluency z-score difference: -0.57, 95% CI: -1.05, -0.10; phonemic fluency z-score difference: -0.48, 95% CI: -0.93, -0.03). There was no evidence that intestinal inflammation mediated the association between Shigella and HAZ or cognitive outcomes.

Conclusions/significance

While Shigella infections were consistently associated with long-term deficits in linear growth, the estimates of the negative associations between Shigella and cognitive outcomes were imprecise and only observed in the Brazil and Tanzania sites. Systemic inflammation was strongly associated with lower semantic and phonemic fluency scores in Brazil only, highlighting the site-specificity of effects.

Shigella infections are common among children in low-resource settings and cause inflammation, which may contribute to poor child development outcomes. We studied children from birth to 6–8 years of age in Brazil, Tanzania, and South Africa to assess whether Shigella infections and markers of inflammation in the first 2 years of life were associated with child development outcomes at school age, including height and cognitive assessment scores. Shigella infections were consistently associated with long-term deficits in linear growth. However, the associations between Shigella and cognitive outcomes were smaller, not statistically significant, and inconsistent across the three sites. There was no evidence that inflammation caused by Shigella explained the associations between Shigella and school-aged outcomes. Systemic inflammation was strongly associated with lower cognitive assessment scores in Brazil but not in the other sites, highlighting the differences in determinants of child development across settings. Quantifying the impact and understanding mechanisms for the effect of early life exposures to Shigella on long-term cognitive outcomes remains challenging.

Sex Differences in Early Childhood Growth in a Resource-Limited Setting: A Secondary Analysis of the Early Life Interventions in Childhood Growth and Development in Tanzania (ELICIT) Study

BACKGROUND

In population-based growth surveys in sub-Saharan Africa, boys have higher rates of growth failure than girls.

OBJECTIVES

Our goal was to assess for the presence, timing, and potential etiology of sex-based differences in length-for-age z score (LAZ), weight-for-age z score (WAZ), and head circumference-for-age z score (HCZ) in a birth cohort in rural Tanzania.

METHODS

We performed a secondary analysis of randomized controlled trial data on 1084 children followed from age <2 wk to 18 mo, assessing anthropometry (measured every 3 mo), illness (hospitalization and monthly maternal report of symptoms), and feeding [monthly maternal report of exclusive breastfeeding (EBF) and complementary solids and liquids (CSLs)]. We used linear regression to assess sex differences in LAZ, WAZ, and HCZ over time.

RESULTS

Although male and female infants had similar anthropometry measures at study entry, males exhibited poorer growth through 6 mo (e.g., 3-mo mean LAZ: males -0.94, females -0.74, P < 0.01; 3-mo mean WAZ: males -0.63, females -0.48, P < 0.05), without significant worsening from 6 to 18 mo. Males had lower HCZ only at 9 mo. In evaluating possible etiologies, mediation analysis failed to identify illness or hospitalization as mediators of poorer growth among males, although at age 3 mo, males with recently reported illness exhibited greater decline in WAZ than females with illness (ΔWAZ: males -0.24, females 0.03, heterogeneity test P = 0.01). Differences in EBF and introduction of CSL did not explain the sex-based growth outcomes.

CONCLUSIONS

In longitudinal analysis, males exhibited more severe growth failure by 3 mo than girls and did not exhibit catchup growth between 6 and 18 mo. Reported symptoms of illness and early introduction of CSL did not appear to be mediators of these sex-based differences, although likely not all sickness was captured by monthly maternal report. Given the early nature of these deficits, LAZ and WAZ measures at 6 mo may be good outcomes for intervention studies targeting improvements in early childhood growth and thriving.

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.

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.

Molecular and non-molecular approaches to etiologic diagnosis of gastroenteritis

Gastroenteritis is a major cause of mortality and morbidity globally and rapid identification of the causative pathogen is important for appropriate treatment and patient management, implementation of effective infection control measures, reducing hospital length of stay, and reducing overall medical costs. Although stool culture and microscopic examination of diarrheal stool has been the primary method for laboratory diagnosis, culture-independent proteomic and genomic tests are receiving increased attention. Antigen tests for stool pathogens are routinely implemented as rapid and simple analytics whereas molecular tests are now available in various formats from high complexity to waived point-of-care tests. In addition, metagenomic next-generation sequencing stands poised for use as a method for both diagnosis and routine characterization of the gut microbiome in the very near future. Analysis of host biomarkers as indicators of infection status and pathogenesis may also become important for prediction, diagnosis, and monitoring of gastrointestinal infection. Here we review current methods and emerging technologies for the etiologic diagnosis of gastroenteritis in the clinical laboratory. Benefits and limitations of these evolving methods are highlighted.

Acute Malnutrition in Children: Pathophysiology, Clinical Effects and Treatment

Acute malnutrition is a nutritional deficiency resulting from either inadequate energy or protein intake. Children with primary acute malnutrition are common in developing countries as a result of inadequate food supply caused by social, economic, and environmental factors. Secondary acute malnutrition is usually due to an underlying disease causing abnormal nutrient loss, increased energy expenditure, or decreased food intake. Acute malnutrition leads to biochemical changes based on metabolic, hormonal, and glucoregulatory mechanisms. Most children with primary acute malnutrition can be managed at home with nutrition-specific interventions (i.e., counseling of parents, ensuring household food security, etc.). In case of severe acute malnutrition and complications, inpatient treatment is recommended. Secondary acute malnutrition should be managed by treating the underlying cause.

The incidence of stunting, the frequency/duration of diarrhea and Acute Respiratory Infection in toddlers

Background: Infectious diseases such as diarrhea and Acute Respiratory Infection (ARI) lead to loss of appetite in children and stunting growth. This study analyzes the relationship between the incidence of stunting and the frequency/duration of diarrhea and ARI in children under five years.

Design and Methods: The stratified random sampling method was used to obtain data from 152 children in 4 villages in Surabaya, East Java, Indonesia.

Results: The results showed that children under the age of five, experience higher stunting duration and longer frequency of diarrhea. The Rho Spearmen Test showed differences in the incidence of stunting with the frequency of diarrhea P = 0.005 (P<α = 0.05), P = 0.003 (P<α = 0.05), with ARI of P =0.001 (P<α = 0.05).

Conclusions: In conclusion, stunting is related to the frequency and duration of diarrheal diseases and ARI, therefore, community- integrated health center need to carryout counseling activities on children less than five years to determine their health status.

Course of perinatal depressive symptoms among South African women: associations with child outcomes at 18 and 36 months

PURPOSE

Latent modelling was used to identify trajectories of depressive symptoms among low-income perinatal women in South Africa. Predictors of trajectories and the association of trajectories with child outcomes were assessed.

METHODS

This is a secondary analysis of data collected among women living in Cape Town settlements (N = 446). Participants were eligible if pregnant and 18 years or older, and included in the analysis if allocated to the control arm (routine perinatal care). Participants were excluded in case of non-singleton birth and baby death. Follow-up assessments were at 2 weeks, 6-, 18-, and 36-month postpartum. Trajectories of depressive symptoms were based on the Edinburgh Postnatal Depression Scale scores until 18-month postpartum, using latent class growth analysis. Child physical, cognitive, socio-emotional, and behavioural outcomes were assessed at 18 and/or 36 months. Univariate and multivariate regressions were used to identify predictors of trajectories and differences in child outcomes.

RESULTS

Four trajectories were identified: chronic low (71.1%), late postpartum (10.1%), early postpartum (14.4%), and chronic high (4.5%). Low social support, unwanted pregnancy, and risky drinking were associated with the chronic high trajectory; unemployment and HIV-positive status with the early postpartum trajectory; and intimate partner violence with the late postpartum trajectory. Weight-to-length and weight-for-age z-scores at 18 months, and weight-for-age z-scores, length-for-age z-scores, emotional symptom, and peer problem scores at 36 months differed across trajectories.

CONCLUSIONS

Severe depressive symptoms in postpartum period have a lasting effect on child physical and socio-emotional outcomes. Multiple screening throughout pregnancy and 1-year postpartum is essential.

Mechanisms linking height to early child development among infants and preschoolers in rural India

Stunting has been negatively associated with children's development. We examined the range of height by testing hypotheses: (a) height is positively associated with children's development, with associations moderated by inflammation and (b) home environments characterized by nurturance and early learning opportunities is positively associated with children's development over time and attenuate associations with height. Data included 513 infants (mean age 8.6 months) and 316 preschoolers (mean age 36.6 months) in rural India from a randomized controlled trial of multiple micronutrient powders (MNPs). Measures included height (height-for-age z-scores based on WHO standards), inflammation (C-reactive protein concentration >5 mg/L), nurturance (HOME Inventory), child development (Mullens Scales of Early Learning), and inhibitory control (preschoolers). Linear mixed effects models accounting for repeated measures, clustering, and confounders were used to assess associations between height and child development over time (infants: enrollment, 6 and 12 months; preschoolers: enrollment and 8 months). Moderating effects of inflammation and nurturance were tested with interaction terms. Among infants and preschoolers, height and nurturance were positively associated with all domains of child development over time, with the exception of inhibitory control. Among preschoolers, in the presence of inflammation, height was not associated with child development. Among infants, but not preschoolers, a nurturant home environment attenuated significant associations between height with fine motor and receptive language development. The mechanisms associated with children's development over time are multifactorial and include direct and indirect associations among nutrition, health, and the home environment, as supported by the Nurturing Care Framework.

Childhood growth and neurocognition are associated with distinct sets of metabolites

Background

Undernutrition is a serious global problem that contributes to increased child morbidity and mortality, impaired neurocognitive development, and decreased educational and economic attainment. Current interventions are only marginally effective, and identification of associated metabolic pathways can offer new strategies for intervention.

Methods

Plasma samples were collected at 9 and 36 months from a subset of the PROVIDE child cohort (n = 130). Targeted metabolomics was performed on bile acids, acylcarnitines, amino acids, phosphatidylcholines, and sphingomyelins. Metabolic associations with linear growth and neurocognitive outcomes at four years were evaluated using correlation and penalized-linear regression analysis as well as conditional random forest modeling.

Findings

Different metabolites were associated with growth and neurocognitive outcomes. Improved growth outcomes were associated with higher concentrations of hydroxy-sphingomyelin and essential amino acids and lower levels of acylcarnitines and bile acid conjugation. Neurocognitive scores were largely associated with phosphatidylcholine species and early metabolic indicators of inflammation. All metabolites identified explain ~45% of growth and neurocognitive variation.

Interpretation

Growth outcomes were predominantly associated with metabolites measured early in life (9 months), many of which were biomarkers of insufficient diet, environmental enteric dysfunction, and microbiome disruption. Hydroxy-sphingomyelin was a significant predictor of improved growth. Neurocognitive outcome was predominantly associated with 36 month phosphatidylcholines and inflammatory metabolites, which may serve as important biomarkers of optimal neurodevelopment. The distinct sets of metabolites associated with growth and neurocognition suggest that intervention may require targeted approaches towards distinct metabolic pathways.

Fund

Bill & Melinda Gates Foundation (OP1173478); National Institutes of Health (AI043596, CA044579).

Child development in the context of biological and psychosocial hazards among poor families in Bangladesh

It is well established that low resource environments early in life can predispose children to adverse health and compromised developmental outcomes. We explore possible mechanistic pathways underlying poor developmental outcomes in children growing up in a low resource setting in urban Bangladesh. We tested associations between psychosocial risks, namely maternal distress and poor caregiving experiences, and biological risks, namely poor growth (HAZ) and inflammation (C-reactive protein: CRP), and children’s developmental outcomes. Child development was measured using the Mullen Scales of Early Learning (MSEL) at 6 and 27 months in one cohort, and using the MSEL and Wechsler Preschool and Primary Scale of Intelligence (WPPSI) at 36 and 60 months respectively in another cohort. In the younger cohort, we found that more inflammation (estimated by the child’s CRP level at four months) predicted lower receptive language scores at 6 months, while more frequent caregiving interactions predicted higher receptive language scores at 6 months. In the older cohort, we found that at 27 months, a child’s growth measured by his or her current HAZ was positively associated with gross motor, visual reception, receptive language, and expressive language scores. In the oldest cohort, we found that higher HAZ and more frequent stimulating activities in the home predicted higher motor and language scores, whereas more inflammation (as estimated by CRP over the first two years of life) predicted lower motor scores at 36 months. At 60 months, we found that HAZ and caregiving experiences were positively associated with verbal IQ, whereas inflammation was negatively associated with verbal IQ. This work identifies malnutrition, inflammation, and caregiving as potential sites of intervention to improve neurodevelopment in children growing up in global poverty.

Independent and combined effects of improved water, sanitation, and hygiene (WASH) and improved complementary feeding on early neurodevelopment among children born to HIV-negative mothers in rural Zimbabwe: Substudy of a cluster-randomized trial

BACKGROUND

Globally, nearly 250 million children (43% of all children under 5 years of age) are at risk of compromised neurodevelopment due to poverty, stunting, and lack of stimulation. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH) and improved infant and young child feeding (IYCF) on early child development (ECD) among children enrolled in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe.

METHODS AND FINDINGS

SHINE was a cluster-randomized community-based 2×2 factorial trial. A total of 5,280 pregnant women were enrolled from 211 clusters (defined as the catchment area of 1-4 village health workers [VHWs] employed by the Zimbabwean Ministry of Health and Child Care). Clusters were randomly allocated to standard of care, IYCF (20 g of small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counseling), WASH (ventilated improved pit latrine, handwashing stations, chlorine, liquid soap, and play yard), and WASH + IYCF. Primary outcomes were child length-for-age Z-score and hemoglobin concentration at 18 months of age. Children who completed the 18-month visit and turned 2 years (102-112 weeks) between March 1, 2016, and April 30, 2017, were eligible for the ECD substudy. We prespecified that primary inferences would be drawn from findings of children born to HIV-negative mothers; these results are presented in this paper. A total of 1,655 HIV-unexposed children (64% of those eligible) were recruited into the ECD substudy from 206 clusters and evaluated for ECD at 2 years of age using the Malawi Developmental Assessment Tool (MDAT) to assess gross motor, fine motor, language, and social skills; the MacArthur-Bates Communicative Development Inventories (CDI) to assess vocabulary and grammar; the A-not-B test to assess object permanence; and a self-control task. Outcomes were analyzed in the intention-to-treat population. For all ECD outcomes, there was not a statistical interaction between the IYCF and WASH interventions, so we estimated the effects of the interventions by comparing the 2 IYCF groups with the 2 non-IYCF groups and the 2 WASH groups with the 2 non-WASH groups. The mean (95% CI) total MDAT score was modestly higher in the IYCF groups compared to the non-IYCF groups in unadjusted analysis: 1.35 (0.24, 2.46; p = 0.017); this difference did not persist in adjusted analysis: 0.79 (-0.22, 1.68; p = 0.057). There was no evidence of impact of the IYCF intervention on the CDI, A-not-B, or self-control tests. Among children in the WASH groups compared to those in the non-WASH groups, mean scores were not different for the MDAT, A-not-B, or self-control tests; mean CDI score was not different in unadjusted analysis (0.99 [95% CI -1.18, 3.17]) but was higher in children in the WASH groups in adjusted analysis (1.81 [0.01, 3.61]). The main limitation of the study was the specific time window for substudy recruitment, meaning not all children from the main trial were enrolled.

CONCLUSIONS

We found little evidence that the IYCF and WASH interventions implemented in SHINE caused clinically important improvements in child development at 2 years of age. Interventions that directly target neurodevelopment (e.g., early stimulation) or that more comprehensively address the multifactorial nature of neurodevelopment may be required to support healthy development of vulnerable children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01824940.

Effect of antenatal and infant micronutrient supplementation on middle childhood and early adolescent development outcomes in Tanzania

Background:

There is growing evidence that nutritional interventions in the first 1,000 days of life may influence long-term health and development outcomes. Few studies have examined the effect of maternal and infant micronutrient supplementation on development outcomes in sub-Saharan Africa.

Methods:

We conducted a follow-up study of two randomized trials of antenatal and infant micronutrient supplementation conducted in Dar es Salaam, Tanzania. We assessed the effect of maternal multiple micronutrient (MMN) supplementation in pregnancy on development of children at 11–14 years of age. We also examined the effect of infant zinc and MMN supplementation on development at 6–8 years of age. We use generalized linear models to assess standardized mean differences (SMDs) in general intelligence, executive function and mental health scores.

Results:

We followed-up 446 children whose mothers were enrolled in the maternal MMN supplementation trial and 365 children who were enrolled in the infant zinc and MMN supplementation trial. We found no effect of maternal MMN supplementation on general intelligence (SMD: −0.03; 95% CI: −0.15, 0.09), executive function (SMD: 0.00; 95% CI: −0.11, 0.11) and mental health scores (SMD: 0.06; 95% CI: −0.10, 0.22). We also found no effect of either infant zinc or MMN supplementation on any of the three development domains (p-values >0.05).

Conclusions:

We found that antenatal MMN supplementation and infant zinc and MMN supplementation did not have a large effect on development outcomes in middle childhood and early adolescence in Tanzania.

Early childhood cognitive development is affected by interactions among illness, diet, enteropathogens and the home environment: findings from the MAL-ED birth cohort study

Background

Millions of children in low-income and middle-income countries (LMICs) are at risk of not reaching their full cognitive potential. Malnutrition and enteric infections in early life are implicated as risk factors; however, most studies on these risks and their associations with cognitive development have failed to adequately account for confounding factors or the accumulation of putative insults. Here, we examine the interaction between infections and illness on cognitive development in LMIC community settings.

Methods

As part of the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) longitudinal birth cohort study, children from eight LMICs were followed from birth to 24 months to understand the influence of repeated enteric infections on child growth and development. Here, data from six sites were employed to evaluate associations between infection, illness, the home environment, micronutrient intake and status, maternal reasoning, and cognitive development at 24 months.

Results

Higher rates of enteropathogen detection and days with illness were associated with lower haemoglobin concentrations, which in turn were associated with lower cognitive scores at 24 months. Children with lower environmental health/safety scores and lower intakes of vitamin B₆ and folate had more enteropathogen detections and illness. Strength of associations varied by weight-for-age in the first 17 days of life; lower weight infants were more susceptible to the negative effects of enteropathogens and illness.

Conclusions

Enteropathogens were negatively related to child cognitive development. However, other factors were more strongly associated with child cognition. Targeting of interventions to improve cognitive development should include a focus on reducing frequency of illness, improving the safety and healthfulness of the child’s environment, and improving dietary intake.

Global disability-adjusted life-year estimates of long-term health burden and undernutrition attributable to diarrhoeal diseases in children younger than 5 years

Background

Diarrhoea is a leading cause of death and illness globally among children younger than 5 years. Mortality and short-term morbidity cause substantial burden of disease but probably underestimate the true effect of diarrhoea on population health. This underestimation is because diarrhoeal diseases can negatively affect early childhood growth, probably through enteric dysfunction and impaired uptake of macronutrients and micronutrients. We attempt to quantify the long-term sequelae associated with childhood growth impairment due to diarrhoea.

Methods

We used the Global Burden of Diseases, Injuries, and Risk Factors Study framework and leveraged existing estimates of diarrhoea incidence, childhood undernutrition, and infectious disease burden to estimate the effect of diarrhoeal diseases on physical growth, including weight and height, and subsequent disease among children younger than 5 years. The burden of diarrhoea was measured in disability-adjusted life-years (DALYs), a composite metric of mortality and morbidity. We hypothesised that diarrhoea is negatively associated with three common markers of growth: weight-for-age, weight-for-height, and height-for-age Z-scores. On the basis of these undernutrition exposures, we applied a counterfactual approach to quantify the relative risk of infectious disease (subsequent diarrhoea, lower respiratory infection, and measles) and protein energy malnutrition morbidity and mortality per day of diarrhoea and quantified the burden of diarrhoeal disease due to these outcomes caused by undernutrition.

Findings

Diarrhoea episodes are significantly associated with childhood growth faltering. We found that each day of diarrhoea was associated with height-for-age Z-score (–0·0033 [95% CI −0·0024 to −0·0041]; p=4·43 × 10⁻¹⁴), weight-for-age Z-score (–0·0077 [–0·0058 to −0·0097]; p=3·19 × 10⁻¹⁵), and weight-for-height Z-score (–0·0096 [–0·0067 to −0·0125]; p=7·78 × 10⁻¹¹). After addition of the DALYs due to the long-term sequelae as a consequence of undernutrition, the burden of diarrhoeal diseases increased by 39·0% (95% uncertainty interval [UI] 33·0–46·6) and was responsible for 55 778 000 DALYs (95% UI 49 125 400–62 396 200) among children younger than 5 years in 2016. Among the 15 652 300 DALYs (95% UI 12 951 300–18 806 100) associated with undernutrition due to diarrhoeal episodes, more than 84·7% are due to increased risk of infectious disease, whereas the remaining 15·3% of long-term DALYs are due to increased prevalence of protein energy malnutrition. The burden of diarrhoea has decreased substantially since 1990, but progress has been greater in long-term (78·7% reduction [95% UI 69·3–85·5]) than in acute (70·4% reduction [95% UI 61·7–76·5]) DALYs.

Interpretation

Diarrhoea represents an even larger burden of disease than was estimated in the Global Burden of Disease Study. In order to adequately address the burden of its long-term sequelae, a renewed emphasis on controlling the risk of diarrhoea incidence may be required. This renewed effort can help further prevent the potential lifelong cost on child health, growth, and overall potential.

Funding

Bill & Melinda Gates Foundation.

Role of maternal health and infant inflammation in nutritional and neurodevelopmental outcomes of two-year-old Bangladeshi children

BACKGROUND

Previous studies have shown maternal, inflammatory, and socioeconomic variables to be associated with growth and neurodevelopment in children from low-income countries. However, these outcomes are multifactorial and work describing which predictors most strongly influence them is lacking.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted a longitudinal study of Bangladeshi children from birth to two years to assess oral vaccine efficacy. Variables pertaining to maternal and perinatal health, socioeconomic status, early childhood enteric and systemic inflammation, and anthropometry were collected. Bayley-III neurodevelopmental assessment was conducted at two years. As a secondary analysis, we employed hierarchical cluster and random forests techniques to identify and rank which variables predicted growth and neurodevelopment. Cluster analysis demonstrated three distinct groups of predictors. Mother's weight and length-for-age Z score (LAZ) at enrollment were the strongest predictors of LAZ at two years. Cognitive score on Bayley-III was strongly predicted by weight-for-age (WAZ) at enrollment, income, and LAZ at enrollment. Top predictors of language included Rotavirus vaccination, plasma IL 5, sCD14, TNFα, mother's weight, and male gender. Motor function was best predicted by fecal calprotectin, WAZ at enrollment, fecal neopterin, and plasma CRP index. The strongest predictors for social-emotional score included plasma sCD14, income, WAZ at enrollment, and LAZ at enrollment. Based on the random forests' predictions, the estimated percentage of variation explained was 35.4% for LAZ at two years, 34.3% for ΔLAZ, 42.7% for cognitive score, 28.1% for language, 40.8% for motor, and 37.9% for social-emotional score.

CONCLUSIONS/SIGNIFICANCE

Birth anthropometry and maternal weight were strong predictors of growth while enteric and systemic inflammation had stronger associations with neurodevelopment. Birth anthropometry was a powerful predictor for all outcomes. These data suggest that further study of stunting in low-income settings should include variables relating to maternal and prenatal health, while investigations focusing on neurodevelopmental outcomes should additionally target causes of systemic and enteric inflammation.

The global problem of childhood diarrhoeal diseases: emerging strategies in prevention and management

Acute diarrhoeal diseases remain a leading cause of global morbidity and mortality particularly among young children in resource-limited countries. Recent large studies utilizing case-control design, prospective sampling and more sensitive and broad diagnostic techniques have shed light on particular pathogens of importance and highlighted the previously under recognized impact of these infections on post-acute illness mortality and growth. Vaccination, particularly against rotavirus, has emerged as a key effective means of preventing significant morbidity and mortality from childhood diarrhoeal disease. Other candidate vaccines against leading diarrhoeal pathogens, such as enterotoxigenic Escherichia coli and Shigella spp., also hold significant promise in further ameliorating the burden of enteric infections in children. Large studies are also currently underway evaluating novel and potential easy-to-implement water, sanitation and hygiene (WASH) preventive strategies. Given the ongoing global burden of this illness, the paucity of new advances in case management over the last several decades remains a challenge. The increasing recognition of post-acute illness mortality and growth impairment has highlighted the need for interventions that go beyond management of dehydration and electrolyte disturbances. The few trials of novel promising interventions such as probiotics have mainly been conducted in high-income settings. Trials of antimicrobials have also been primarily conducted in high-income settings or in travellers from high-income settings. Bloody diarrhoea has been shown to be a poor marker of potentially treatable bacterial enteritis, and rising antimicrobial resistance has also made empiric antimicrobial therapy more challenging in many settings. Novel effective and sustainable interventions and diagnostic strategies are clearly needed to help improve case management. Diarrhoeal disease and other enteric infections remain an unmet challenge in global child health. Most promising recent developments have been focused around preventive measures, in particular vaccination. Further advances in prevention and case management including the possible use of targeted antimicrobial treatment are also required to fully address this critical burden on child health and human potential.

Hubungan Riwayat Penyakit Diare dan Praktik Higiene dengan Kejadian Stunting pada Balita Usia 24-59 Bulan di Wilayah Kerja Puskesmas Simolawang, Surabaya

Background: Stunting among children is a chronic impact of a long-term low quality dietary intake accompanied by infectious diseases and environmental issues. Bad hygiene practices can lead to diarrheal disease that can make children loss some essential nutrients for body growth. Objectives: This research aimed to analyze the relations between history of diarrheal disease and hygiene practices with stunting incidences among children aged 24-59 months. Methods: This research was designed with case control. The case was stunting children and the control was non-stunting children in the work area of Puskesmas Simolawang with sample of 33 children each. The relation between variables was tested using Chi Square and Odd Ratio. Results: The majority of children in stunting group had the diarrheal disease frequently (72.7%), whereas children in non stunting group had the diarrheal disease rarely (57.6%). Most of children caretaker in stunting group had bad hygiene practices (75.8%), whereas children caretaker in non stunting group had good hygiene practices (60.6%). The history of diarrheal disease (p=0.025, OR=3.619) and hygiene practices (p=0.006, OR=4.808) had significant relation with stunting. Conclusion: The frequent diarrheal diseases and poor hygiene practices increase the risk of stunting 3.619 and 4.808 times among children aged 24-59 months. It can be recommended that there should be a monitoring of infectious disease among children held by Intergrated Health Post and should be held an education related to parenting styles, especially hygiene practices, because a good parenting styles could lead to a better nutritional status.ABSTRAK Latar belakang: Stunting pada anak merupakan dampak yang bersifat kronis dari konsumsi diet berkualitas rendah yang terus menerus dan didukung oleh penyakit infeksi dan masalah lingkungan. Praktik higiene yang buruk dapat menyebabkan balita terserang penyakit diare yang nantinya dapat menyebabkan anak kehilangan zat-zat gizi yang penting bagi pertumbuhan.Tujuan: Penelitian ini bertujuan untuk menganalisis hubungan riwayat penyakit diare dan praktik higiene dengan kejadian stunting pada balita usia 24-59 bulan.Metode: Penelitian menggunakan desain kasus kontrol. Sampel kasus adalah balita stunting dan sampel kontrol adalah balita tidak stunting di wilayah kerja Puskesmas Simolawang dengan jumlah masing-masing 33. Hubungan dan besar risiko antara variabel diuji menggunakan Chi Square dan Odd Ratio.Hasil: Sebagian besar anak pada kelompok stunting sering mengalami diare (72,7%) sedangkan pada kelompok tidak stunting jarang mengalami diare (57,6%). Sebagian besar pengasuh pada kelompok stunting memiliki praktik higiene yang buruk (75,8%), sedangkan pada kelompok tidak stunting memiliki praktik higiene yang baik (60,6%). Riwayat penyakit diare (p=0,025, OR=3,619) dan praktik higiene (p=0,006, OR=4,808) memiliki hubungan yang signifikan dengan kejadian stunting. Kesimpulan: Riwayat diare yang terjadi secara sering dalam 3 bulan terakhir dan praktik higiene yang buruk meningkatkan risiko sebesar 3,619 dan 4,808 kali terhadap kejadian stunting pada balita usia 24-59 bulan. Hal yang dapat disarankan adalah adanya pemantauan terkait riwayat penyakit infeksi pada balita oleh posyandu setempat dan diadakan penyuluhan terkait dengan pola asuh pada anak, khususnya praktik higiene, karena pola asuh yang baik dapat berdampak kepada status gizi yang lebih baik.

Hubungan Ketahanan Pangan dan Penyakit Diare dengan Stunting pada Balita 13-48 Bulan di Kelurahan Manyar Sabrangan, Surabaya

 Background: Stunting is an acute malnutrition that is one of the leading causes of death in under-five children in the world and can impact on low quality of life in the future. Household food security and infectious diseases especially diarrhea in under-five children are indicated to be factors that cause the stunting state. Toddlers 13-48 months old are likely have a high risk for disease and its effects. Stunting in under-five children is closely related to food insecurity of the family and diarrheal diseases by the children.Objectives: The purpose of this study was to analyze the association of food security of the family and diarrheal diseases to stunting. Methods: This research was an observational analytic with cross sectional design. The sample was 68 children under-five age 13-48 months in Manyar Sabrangan, Mulyorejo Sub-district, Surabaya. Selection of sample was using simple random sampling with lottery technique. The data were collected by interview method with questionnaire. Food security was accessed by US-HFSSM questionnaire. Spearman correlation test was used in the statistical analysis (α=0.05). Results: The data showed that the percentage of stunting, diarrhea, and household insecurity respectively 30.9%, 19.1%, and 61.8%. There was an association between food insecurity with stunting (p<0.05). There was not an association between diarrhea with stunting (p>0.05). Conclusions: It is necessary for family to have a coping strategy to avoid long-term food insecurity. There is another factor such as a history of food intake that may be able to affect stunting in addition to diarrhea.ABSTRAK Latar Belakang: Stunting merupakan keadaan kekurangan gizi akut yang menjadi salah satu penyebab kematian pada balita di dunia dan dapat berdampak pada kualitas kehidupan yang rendah di masa depan. Ketahanan pangan keluarga dan kejadian penyakit infeksi yang dialami balita terutama diare diindikasikan menjadi faktor yang dapat menyebabkan keadaan stunting. Balita usia 13-48 bulan merupakan kelompok yang rentan terhadap penyakit dan dampaknya. Keadaan stunting erat kaitannya dengan kerawanan pangan keluarga dan penyakit infeksi seperti diare yang dialami balita.Tujuan: Untuk menganalisis hubungan ketahanan pangan keluarga dan penyakit diare dengan keadaan stunting balita.Metode: Penelitian ini merupakan penelitian observasional analitik dengan rancang cross sectional. Sampel dalam penelitian ini adalah 68 balita usia 13-48 bulan di Kelurahan Manyar Sabrangan Kecamatan Mulyorejo Kota Surabaya. Pemilihan sampel menggunakan simple random sampling dengan teknik lotre. Pengambilan data dilakukan dengan metode wawancara dengan kuesioner. Ketahanan pangan diukur dengan menggunakan kuesioner United Stated-Household Food Security Survey Module (US-HFSSM). Analisis statistik dilakukan dengan menggunakan uji korelasi spearman (α=0,05).Hasil: Hasil menunjukkan bahwa sebanyak 30,9% balita mengalami stunting, 19,1% mengalami diare, dan 61,8% berada pada keadaan rawan pangan. Ketahanan pangan keluarga dan keadaan stunting menunjukkan adanya hubungan yang signifikan (p<0,05). Penyakit diare balita dan keadaan stunting tidak menunjukkan adanya hubungan yang signifikan (p>0,05).Kesimpulan: Dibutuhkan coping strategi dalam keluarga untuk mengatasi masalah kerawanan pangan yang terus-menerus. Terdapat faktor lain seperti riwayat asupan makanan yang dapat mempengaruhi stunting selain penyakit diare.

Rapid enteric testing to permit targeted antimicrobial therapy, with and without Lactobacillus reuteri probiotics, for paediatric acute diarrhoeal disease in Botswana: A pilot, randomized, factorial, controlled trial

Introduction

Diarrhoeal disease is the second-leading cause of death in young children. Current guidelines recommend treating children with acute non-bloody diarrhea with oral rehydration solutions and zinc, but not antimicrobials. However, in many resource-limited settings, infections with treatable enteric bacterial and protozoan pathogens are common. Probiotics have shown promise as an adjunct treatment for diarrhoea but have not been studied in sub-Saharan Africa.

Methods

We conducted a pilot, factorial, randomized, placebo-controlled trial of children aged 2–60 months hospitalized in Botswana for acute non-bloody diarrhoea. A rapid test-and-treat intervention, consisting of multiplex PCR testing of rectal swabs taken at enrolment, accompanied by targeted antimicrobial therapy if treatable pathogens were detected, was compared to the reference standard of no stool testing. Additionally, Lactobacillus reuteri DSM 17938 x 60 days was compared to placebo treatment. The main objective of this pilot study was to assess feasibility. The primary clinical outcome was the increase in age-standardized height (HAZ) at 60 days adjusted for baseline HAZ.

Results

Seventy-six patients were enrolled over a seven-month study period. We judged that the recruitment rate, lab processing times, communication protocols, provision of specific antimicrobials, and follow-up rates were acceptable. Compared to the reference arm (no stool testing and placebo treatment), the combination of the rapid test-and-treat strategy plus L. reuteri DSM 17938 was associated with an increase of 0.61 HAZ (95% CI 0.09–1.13) and 93% lower odds of recurrent diarrhoea (OR 0.07, 95%CI 0.01–0.61) at 60 days.

Discussion

We demonstrated that it was feasible to evaluate the study interventions in Botswana. Despite the small sample size, we observed a statistically significant increase in HAZ at 60 days and significantly lower odds of recurrent diarrhoea in children receiving both rapid test-and-treat and L. reuteri. There is sufficient evidence to warrant proceeding with a larger follow-up trial in a similar setting.

Use of Serologic Responses against Enteropathogens to Assess the Impact of a Point-of-Use Water Filter: A Randomized Controlled Trial in Western Province, Rwanda

Diarrhea is a leading contributor to childhood morbidity and mortality in sub-Saharan Africa. Given the challenge of blinding most water, sanitation, and hygiene (WASH) interventions, diarrheal disease outcome measures in WASH intervention trials are subject to potential bias and misclassification. Using the platform of a cluster-randomized controlled trial of a household-based drinking water filter in western province, Rwanda, we assessed the impact of the drinking water filter on enteric seroconversion in young children as a health outcome and examined the association between serologic responses and caregiver-reported diarrhea. Among the 2,179 children enrolled in the trial, 189 children 6-12 months of age were enrolled in a nested serology study. These children had their blood drawn at baseline and 6-12 months after the intervention was distributed. Multiplex serologic assays for Giardia, Cryptosporidium, Entamoeba histolytica, norovirus, Campylobacter, enterotoxigenic Escherichia coli and Vibrio cholerae were performed. Despite imperfect uptake, receipt of the water filter was associated with a significant decrease in seroprevalence of IgG directed against Cryptosporidium parvum Cp17 and Cp23 (relative risk [RR]: 0.62, 95% confidence interval [CI]: 0.44-0.89). Serologic responses were positively associated with reported diarrhea in the previous 7 days for both Giardia intestinalis (RR: 1.94, 95% CI: 1.04-3.63) and C. parvum (RR: 2.21, 95% CI: 1.09-4.50). Serologic responses for all antigens generally increased in the follow-up round, rising sharply after 12 months of age. The water filter is associated with reduced serologic responses against C. parvum, a proxy for exposure and infection; therefore, serologic responses against protozoa may be a suitable health outcome measure for WASH trials among children with diarrhea.

Diarrheal disease and enteric infections in LMIC communities: how big is the problem?

Studies of enteric diseases have historically focused on observations of clinical diarrhea as a cause of mortality and morbidity. Emerging evidence suggests that diarrhea dramatically underestimates both exposure to enteropathogens and the long-term consequences arising from infection. High burden of pathogens in the gut, even in the absence of diarrhea, is common in infants in low and middle income countries. Continual challenge by pathogens, in conjunction with an inadequate diet stimulates an inflammatory disease that alters the structure of the gut, metabolic and immunological pathways and changes the microbiome. Both diarrhea and enteropathogen infection have been associated with reduced growth, reduced cognitive development, and reduced vaccine efficacy suggesting that the burden of diarrheal disease is dramatically underestimated.

An external evaluation of the Diarrhea Alleviation through Zinc and ORS Treatment (DAZT) program in Gujarat and Uttar Pradesh, India

Background

To address inadequate coverage of oral rehydration salts (ORS) and zinc supplements for the treatment of diarrhea among children under–five, the Diarrhea Alleviation through Zinc and ORS Treatment (DAZT) program was carried out from 2011–2013 in Gujarat and from 2011–2014 in Uttar Pradesh (UP), India. The program focused on improving the diarrhea treatment practices of public and private sector providers.

Methods

We conducted cross–sectional household surveys in program districts at baseline and endline and constructed state–specific logistic regression models with generalized estimating equations to assess changes in ORS and zinc treatment during the program period.

Results

Between baseline and endline, zinc coverage increased from 2.5% to 22.4% in Gujarat and from 3.1% to 7.0% in UP; ORS coverage increased from 15.3% to 39.6% in Gujarat but did not change in UP. In comparison to baseline, children with diarrhea in the two–weeks preceding the endline survey had higher odds of receiving zinc treatment in both Gujarat (odds ratio, OR = 11.2; 95% confidence interval (CI) 6.4–19.3) and UP (OR = 2.4; 95% CI 1.4–3.9), but the odds of receiving ORS only increased in Gujarat (OR = 3.6; 95% CI 2.7–4.8; UP OR = 0.9; 95% CI 0.7–1.2). Seeking care outside the home, especially from a public sector source, was associated with higher odds of receiving ORS and zinc.

Conclusions

During the duration of the DAZT program, there were modest improvements in the treatment of diarrhea among young children. Future programs should build upon and accelerate this trend with continued investment in public and private sector provider training and supply chain sustainability, in addition to targeted caregiver demand generation activities.

Detailed Investigation of the Immunodominant Role of O-Antigen Stoichiometric O-Acetylation as Revealed by Chemical Synthesis, Immunochemistry, Solution Conformation and STD-NMR Spectroscopy for Shigella flexneri 3a

Shigella flexneri 3a causes bacillary dysentery. Its O-antigen has the {2)-[α-d-Glcp-(1→3)]-α-l-Rhap-(1→2)-α-l-Rhap-(1→3)-[Ac→2]-α-l-Rhap-(1→3)-[Ac→6]≈40 % -β-d-GlcpNAc-(1→} ([(E)ABAc CAc D]) repeating unit, and the non-O-acetylated equivalent defines S. flexneri X. Propyl hepta-, octa-, and decasaccharides sharing the (E')A'BAc CD(E)A sequence, and their non-O-acetylated analogues were synthesized from a fully protected BAc CD(E)A allyl glycoside. The stepwise introduction of orthogonally protected mono- and disaccharide imidate donors was followed by a two-step deprotection process. Monoclonal antibody binding to twenty-six S. flexneri types 3a and X di- to decasaccharides was studied by an inhibition enzyme-linked immunosorbent assay (ELISA) and STD-NMR spectroscopy. Epitope mapping revealed that the 2C -acetate dominated the recognition by monoclonal IgG and IgM antibodies and that the BAc CD segment was essential for binding. The glucosyl side chain contributed to a lesser extent, albeit increasingly with the chain length. Moreover, tr-NOESY analysis also showed interaction but did not reveal any meaningful conformational change upon antibody binding.

Combination vaccines against diarrheal diseases

Diarrheal diseases remain a leading cause of global childhood mortality and morbidity. Several recent epidemiological studies highlight the rate of diarrheal diseases in different parts of the world and draw attention to the impact on childhood growth and survival. Despite the well-documented global burden of diarrheal diseases, currently there are no combination diarrheal vaccines, only licensed vaccines for rotavirus and cholera, and Salmonella typhi-based vaccines for typhoid fever. The recognition of the impact of diarrheal episodes on infant growth, as seen in resource-poor countries, has spurred action from governmental and non-governmental agencies to accelerate research toward affordable and effective vaccines against diarrheal diseases. Both travelers and children in endemic countries will benefit from a combination diarrheal vaccine, but it can be argued that the greater proportion of any positive impact will be on the public health status of the latter. The history of combination pediatric vaccines indicate that monovalent or single disease vaccines are typically licensed first prior to formulation in a combination vaccine, and that the combinations themselves undergo periodic revision in response to need for improvement in safety or potential for wider coverage of important pediatric pathogens. Nevertheless combination pediatric vaccines have proven to be an effective tool in limiting or eradicating communicable childhood diseases worldwide. The landscape of diarrheal vaccine candidates indicates that there now several in active development that offer options for potential testing of combinations to combat those bacterial and viral pathogens responsible for the heaviest disease burden—rotavirus, ETEC, Shigella, Campylobacter, V. cholera and Salmonella.

Global research priorities for infections that affect the nervous system

Infections that cause significant nervous system morbidity globally include viral (for example, HIV, rabies, Japanese encephalitis virus, herpes simplex virus, varicella zoster virus, cytomegalovirus, dengue virus and chikungunya virus), bacterial (for example, tuberculosis, syphilis, bacterial meningitis and sepsis), fungal (for example, cryptococcal meningitis) and parasitic (for example, malaria, neurocysticercosis, neuroschistosomiasis and soil-transmitted helminths) infections. The neurological, cognitive, behavioural or mental health problems caused by the infections probably affect millions of children and adults in low- and middle-income countries. However, precise estimates of morbidity are lacking for most infections, and there is limited information on the pathogenesis of nervous system injury in these infections. Key research priorities for infection-related nervous system morbidity include accurate estimates of disease burden; point-of-care assays for infection diagnosis; improved tools for the assessment of neurological, cognitive and mental health impairment; vaccines and other interventions for preventing infections; improved understanding of the pathogenesis of nervous system disease in these infections; more effective methods to treat and prevent nervous system sequelae; operations research to implement known effective interventions; and improved methods of rehabilitation. Research in these areas, accompanied by efforts to implement promising technologies and therapies, could substantially decrease the morbidity and mortality of infections affecting the nervous system in low- and middle-income countries.

Practical Guidance for Clinical Microbiology Laboratories: Diagnosis of Bacterial Gastroenteritis

Bacterial gastroenteritis is a disease that is pervasive in both the developing and developed worlds. While for the most part bacterial gastroenteritis is self-limiting, identification of an etiological agent by bacterial stool culture is required for the management of patients with severe or prolonged diarrhea, symptoms consistent with invasive disease, or a history that may predict a complicated course of disease. Importantly, characterization of bacterial enteropathogens from stool cultures in clinical laboratories is one of the primary means by which public health officials identify and track outbreaks of bacterial gastroenteritis. This article provides guidance for clinical microbiology laboratories that perform stool cultures. The general characteristics, epidemiology, and clinical manifestations of key bacterial enteropathogens are summarized. Information regarding optimal specimen collection, transport, and processing and current diagnostic tests and testing algorithms is provided. This article is an update of Cumitech 12A (P. H. Gilligan, J. M. Janda, M. A. Karmali, and J. M. Miller, Cumitech 12A, Laboratory diagnosis of bacterial diarrhea, 1992).

Global burden of childhood diarrhea and interventions

PURPOSE OF REVIEW

Diarrhea is a leading cause of morbidity and mortality among children under 5 years in low-income and middle-income countries. Over the past 2 decades under-five mortality has decreased substantially, but reductions have been uneven and unsatisfactory in resource-poor regions.

RECENT FINDINGS

There are known interventions which can prevent diarrhea or manage children who suffer from it. Interventions with proven effectiveness at the prevention level include water, sanitation, and hygiene interventions, breastfeeding, complementary feeding, vitamin A and zinc supplementation, and vaccines for diarrhea (rotavirus and cholera). Oral rehydration solution, zinc treatment, continued feeding, and antibiotic treatment for certain strains of diarrhea (cholera, Shigella, and cryptosporidiosis) are effective strategies for treatment of diarrhea. The recent Lancet series using the 'Lives Saved' tool suggested that if these identified interventions were scaled up to a global coverage to at least 80%, and immunizations to at least 90%; almost all deaths due to diarrhea could be averted.

SUMMARY

The current childhood mortality burden highlights the need of a focused global diarrhea action plan. The findings suggest that with proper packaging of interventions and delivery platforms, the burden of childhood diarrhea can be reduced to a greater extent. All that is required is greater attention and steps toward right direction.

Appropriate Management of Acute Diarrhea in Children Among Public and Private Providers in Gujarat, India: A Cross-Sectional Survey

Training public-sector providers to treat diarrhea in children with low-osmolarity oral rehydration salts and zinc appeared to be effective. Among private providers, drug-detailing visits by pharmaceutical representatives seemed less effective, particularly in improving knowledge of the correct dosage and duration of zinc treatment. Consistent supplies and sufficient attention to training all health care cadres, especially community health workers who may be new to diarrhea treatment and informal-sector providers who are typically excluded from formal training, are critical to improving knowledge and prescribing behaviors.

Diarrhea remains a leading cause of morbidity and mortality among children under 5 years of age in low- and middle-income countries. In 2006, the Indian government formally endorsed the World Health Organization guidelines that introduced zinc supplementation and low-osmolarity oral rehydration salts (ORS) for the treatment of diarrhea. Despite this, zinc is rarely prescribed and has not been available in the public sector in India until very recently. The Diarrhea Alleviation Through Zinc and ORS Treatment (DAZT) project was implemented in Gujarat between 2011 and 2013 to accelerate the uptake of zinc and ORS among public and private providers in 6 rural districts. As part of an external evaluation of DAZT, we interviewed 619 randomly selected facility- and community-based public and private providers 2–3 months after a 1-day training event had been completed (or, in the case of private providers, after at least 1 drug-detailing visit by a pharmaceutical representative had occurred) and supplies were in place. The purpose of the interviews was to assess providers’ knowledge of appropriate treatment for diarrhea in children, reported treatment practices, and availability of drugs in stock. More than 80% of all providers interviewed reported they had received training or a drug-detailing visit on diarrheal treatment in the past 6 months. Most providers in all cadres (range, 68% to 100%) correctly described how to prepare ORS and nearly all (range, 90% to 100%) reported routinely prescribing it to treat diarrhea in children. Reported routine prescription of zinc was lower, ranging from 62% among private providers to 96% among auxiliary nurse-midwives. Among providers who reported ever not recommending zinc (n = 242), the 2 most frequently reported reasons for not doing so were not completely understanding zinc for diarrhea treatment and not having zinc in stock at the time of contact with the patient. In a multiple logistic regression analysis, recent training or drug-detailing visits and having zinc in stock were associated with reported zinc prescribing (P<.05). Recent training among public providers was significantly associated with having correct knowledge of zinc treatment duration and dosage, but the same was not true of drug-detailing visits among private providers. Treating diarrhea with zinc and low-osmolarity ORS is new for public and private providers in India and other low- and middle-income countries. Sufficient training and logistics support to ensure consistent supplies are critical if providers are to begin routinely treating all diarrhea episodes with zinc and ORS.

Linear growth and child development in low- and middle-income countries: a meta-analysis

BACKGROUND AND OBJECTIVE

The initial years of life are critical for physical growth and broader cognitive, motor, and socioemotional development, but the magnitude of the link between these processes remains unclear. Our objective was to produce quantitative estimates of the cross-sectional and prospective association of height-for-age z score (HAZ) with child development.

METHODS

Observational studies conducted in low- and middle-income countries (LMICs) presenting data on the relationship of linear growth with any measure of child development among children <12 years of age were identified from a systematic search of PubMed, Embase, and PsycINFO. Two reviewers then extracted these data by using a standardized form.

RESULTS

A total of 68 published studies conducted in 29 LMICs were included in the final database. The pooled adjusted standardized mean difference in cross-sectional cognitive ability per unit increase in HAZ for children ≤ 2 years old was +0.24 (95% confidence interval [CI], 0.14-0.33; I(2) = 53%) and +0.09 for children > 2 years old (95% CI, 0.05-0.12; I(2) = 78%). Prospectively, each unit increase in HAZ for children ≤ 2 years old was associated with a +0.22-SD increase in cognition at 5 to 11 years after multivariate adjustment (95% CI, 0.17-0.27; I(2) = 0%). HAZ was also significantly associated with earlier walking age and better motor scores (P < .05).

CONCLUSIONS

Observational evidence suggests a robust positive association between linear growth during the first 2 years of life with cognitive and motor development. Effective interventions that reduce linear growth restriction may improve developmental outcomes; however, integration with environmental, educational, and stimulation interventions may produce larger positive effects.

Diarrhea, stimulation and growth predict neurodevelopment in young North Indian children

BACKGROUND AND OBJECTIVE

Infants and young children in low to middle-income countries are at risk for adverse neurodevelopment due to multiple risk factors. In this study, we sought to identify stimulation and learning opportunities, growth, and burden of respiratory infections and diarrhea as predictors for neurodevelopment.

METHODS

We visited 422 North Indian children 6 to 30 months old weekly for six months. Childhood illnesses were assessed biweekly. At end study, we assessed neurodevelopment using the Ages and Stages Questionnaire 3rd ed. (ASQ-3) and gathered information on stimulation and learning opportunities. We identified predictors for ASQ-3 scores in multiple linear and logistic regression models.

RESULTS

We were able to explain 30.5% of the variation in the total ASQ-3 score by the identified predictors. When adjusting for child characteristics and annual family income, stimulation and learning opportunities explained most of the variation by 25.1%. Height for age (standardized beta: 0.12, p<.05) and weight for height z-scores (std. beta: 0.09, p<.05) were positively associated with the total ASQ-3 score, while number of days with diarrhea was negatively associated with these scores (std. beta: -0.13, p<0.01).

CONCLUSION

Our results support the importance of early child stimulation and general nutrition for child development. Our study also suggests that diarrhea is an additional risk factor for adverse neurodevelopment in vulnerable children.

Differential estimates of underweight-for-age and growth related morbidity according to different growth standards in Indian children

OBJECTIVE

To compare the four different growth standards currently used in India [WHO (World Health Organization); NCHS (National Center for Health Statistics); ICDS (Integrated Child Development Scheme); IAP (Indian Academy of Pediatrics)] and determine which better predicts growth related morbidity in children after 3 mo of follow-up.

METHODS

The present cohort study was done at Indira Gandhi Government Medical College and Hospital, Nagpur, India. Eligible children were those who had; > 3 unformed stools in the prior 24 h, the duration of their diarrhea was up to 72 h; and they were able to accept oral fluids or feeds. Main outcome measures were classification of the malnutrition status as per each of the four growth standards by weight-for-age and weight-for-height z scores at three months follow-up.

RESULTS

A total of 724 children were included. Mean age was 17.8 mo; 40.6 % were ≤ 12 mo and 59.1 % were males. Estimates of malnourished varied by the four standards, (NCHS, 62.2 % to IAP, 7.4 %). When separated into 'malnourished' and 'severely malnourished' categories, differences were greater, (NCHS, 27.9 % vs. ICDS, 1.9 %). Overall agreement was 'fair' (0.2435, z = 22.21, p = 0.0000). After follow-up, children who were 'severely malnourished' gained more weight than the 'malnourished'group; however, mean weight differed by the four charts [e.g., IAP 767 g (SD ± 611 g), vs. ICDS 884.7 g (SD ± 778 g)].

CONCLUSIONS

Growth standards reported different rates of malnourished categories. The utility of the standards to detect children who are constitutionally vs. pathologically small is questionable. Monitoring the nutritional status of children at both the individual level and at population level has implications for clinical practice, policy development and resource allocation.

Recommendations regarding the development of combined enterotoxigenic Eschericha coli and Shigella vaccines for infants

PATH hosted a workshop on October 14 and 15, 2013 in Washington, DC to solicit expert opinions on the potential merits and challenges of developing combined enterotoxigenic Escherichia coli (ETEC) and Shigella vaccine products to benefit children in developing countries. This article summarizes the key issues raised during the workshop and provides an analysis of the recommendations regarding the strategic, clinical and regulatory, and manufacturing considerations for the development of a combined enteric vaccine, which aim to guide future vaccine development efforts and donor investment strategies in this area. Notwithstanding the potential technical, legal, financial, and other constraints that would be faced in developing a combined ETEC/Shigella vaccine, it is clear that this is the preferred approach over standalone products. There are many advantages to a combined vaccine, such as the potential cost-effectiveness and easier logistics of introducing a combined vaccine instead of two standalone vaccines in low-resource, endemic countries.

Early childhood diarrhoeal diseases and cognition: are we missing the rest of the iceberg?

Risk factors which interfere with cognitive function are especially important during the first 2 years of life - a period referred to as early child development and a time during which rapid growth and essential development occur. Malnutrition, a condition whose effect on cognitive function is well known, has been shown to be part of a vicious cycle with diarrhoeal diseases, and the two pathologies together continue to be the leading cause of illness and death in young children in developing countries. This paper reviews the burden of early childhood diarrhoeal diseases globally and the emerging evidence of their relationship with global disparities in neurocognitive development. The strength of evidence which indicates that the severe childhood diarrhoeal burden may be implicated in cognitive impairment of children from low- and middle-income counties is discussed. Findings suggest that greater investment in multi-site, longitudinal enteric infection studies that assess long-term repercussions are warranted. Furthermore, economic analyses using the concept of human capital should play a key role in advancing our understanding of the breadth and complexities of the health, social and economic ramifications of early childhood diarrhoeal diseases and enteric infections. This broadened awareness can serve to help advocate for more effective interventions, particularly in developing economies.

Global health and development in early childhood

Health and nutritional risks co-occur in the lives of children under the age of 2 years who live in developing countries. We review evidence showing how these risks, in addition to inadequate psychosocial stimulation, prevent children from developing expected cognitive and language abilities. A systematic review and meta-analysis of 21 interventions aimed at enhancing stimulation and 18 interventions that provided better nutrition--all conducted since 2000--revealed that stimulation had a medium effect size of 0.42 and 0.47 on cognitive and language development, respectively, whereas nutrition by itself had a small effect size of 0.09. The implementation processes of these interventions are described and compared. A number of unresolved issues are outlined and discussed, including ways to maximize parental health behavior change, assess mediators that account for intervention effects, and expand the assessment of young children's brain functions that underlie language and cognition and are affected by nutrition and stimulation.

Systematic review of the economic value of diarrheal vaccines

Diarrheal disease is a leading cause of child mortality in low-income settings and morbidity across a range of settings. A growing number of studies have addressed the economic value of new and emerging vaccines to reduce this threat. We conducted a systematic review to assess the economic value of diarrheal vaccines targeting a range of pathogens in different settings. The majority of studies focused on the economic value of rotavirus vaccines in different settings, with most of these concluding that vaccination would provide significant economic benefits across a range of vaccine prices. There is also evidence of the economic benefits of cholera vaccines in specific contexts. For other potential diarrheal vaccines data are limited and often hypothetical. Across all target pathogens and contexts, the evidence of economic value focuses the short-term health and economic gains. Additional information is needed on the broader social and long-term economic value of diarrhea vaccines.

Recent advances in understanding the long-term sequelae of childhood infectious diarrhea

Worldwide, early childhood infectious diarrhea continues to be a significant concern. Diarrheal illness affects the world's youngest and most vulnerable citizens disproportionately. Estimates are that over 70 % of deaths from diarrhea occur in people younger than 24 months of age. Diarrhea and environmental enteropathy have been associated with growth failure and stunting. In addition, the burden of enteric disease also leads to cognitive and academic losses, thus resulting in loss of human capital and economic productivity. While considerable progress has been made on preventing and treating childhood diarrheal illness, the mortality and morbidity still remain unacceptably high. This paper reviews recent (mainly from 2013) publications surrounding the global burden of childhood diarrhea and the implications for long-term sequelae.