Environmental Enteric Dysfunction and Growth Failure/Stunting in Global Child Health

Daily Complementary Feeding With Eggs Improves Fibroblast Growth Factor 21 in Infants

This secondary analysis of the Eggcel-growth study investigated the effect of daily egg intake for 6 months in infants aged 6-9 months on environmental enteric dysfunction (EED) biomarkers and the association of EED markers with growth faltering. A randomised controlled trial was conducted in Jouberton, South Africa, among 500 infants randomly assigned equally to either an intervention group receiving a daily chicken egg or a control group. Both groups were followed up for 6 months. Data on infant and maternal sociodemographic information and anthropometric status of infants were collected. EED and inflammatory markers were analysed using Q-Plex Human EED (11-Plex) assay. There was a significant reduction in fibroblast growth factor 21 (FGF21) concentration in the intervention group (B = -0.132; 95% CI -0.255, -0.010; p = 0.035). Baseline, insulin-like growth factor 1 (IGF-1) was positively associated with endpoint length-for-age z-score (LAZ), weight-for-age z-score (WAZ) and weight-for-length z-score (WLZ) and there was an inverse relationship between baseline FGF21 and intestinal fatty acid-binding protein (I-FABP) with endpoint growth indicators. Baseline IGF-1 was positively associated with reduced odds of wasting, stunting and being underweight (p < 0.001) and baseline FGF21 was associated with increased odds of stunting (p = 0.002), wasting (p = 0.031) and being underweight (p = 0.035). There was a 20% increased odds of stunting with baseline I-FABP (p = 0.045) and a 30% increased odds of being underweight with baseline soluble CD14 (p = 0.039). Complementary feeding with eggs decreased growth hormone resistance (reduced FGF21 levels); however, FGF21 and I-FABP levels were linked to increased growth faltering. Trial Registration: ClinicalTrials.gov: NCT05168085.

Novel gastrointestinal tools (GI Tools) for evaluating gut functional capacity in adults with environmental enteropathy in Zambia and Zimbabwe: A cross-sectional study protocol

Background

Environmental enteropathy (EE) is a highly prevalent subclinical inflammatory intestinal disorder associated with growth failure, impaired neurocognitive development, poor response to oral vaccines, and micronutrient deficiencies. However, EE research and clinical trials are hampered by the lack of non-invasive tools for measuring intestinal function in detail. This study aims to develop new tools for the measurement of multiple domains of gut functional capacity.

Methods

The GI TOOLS project is a cross-sectional study that will recruit adults aged 18-65 years with EE in Lusaka, Zambia. Each participant will undergo assessment of gut functional capacity using novel near-point-of-care tools and provide multiple samples for detailed laboratory analyses. Participants will also undergo endoscopy for collection of duodenal biopsies. Novel techniques include stable isotopes approaches to measuring digestion, absorption, and bidirectional transmucosal amino acid flux, a non-invasive fluorescence tool for real-time evaluation of gut permeability, and assessment of reverse permeation of intravenous antibiotics to be carried out separately in Zimbabwe. Stool and duodenal microbiome sequencing using MinION sequencing, metabolome analysis applied to plasma and intestinal fluids, blood immune cell phenotyping, in vitro epithelial barrier models, and duodenal immunohistochemistry will also be used to explore EE in depth. These will all be integrated with gold standard histology and mucosal morphometry, alongside lactulose permeation data, and stool and plasma biomarker analysis. The protocol has been approved by ethics committees and regulators in Zambia, Zimbabwe, and the UK. Participants will give informed consent before they can participate.

Anticipated outcomes

Based on this extensive phenotyping, tests will be developed which can be simplified and refined for use in adults and children with EE, and for clinical trials. Findings from this project will be disseminated through in-person meetings with caregivers and regulatory bodies, presentations at conferences and in peer-reviewed journals.

Markers of Environmental Enteric Dysfunction are Associated with Poor Growth and Developmental Outcomes among Young Children in Lusaka, Zambia

OBJECTIVE

To examine cross-sectional relationships between biomarkers of environmental enteric dysfunction (EED), an acquired subclinical condition of the small intestine, and anthropometric and developmental outcomes among children in Lusaka, Zambia.

STUDY DESIGN

Serum samples were collected from 240 children aged 27 to 35 months enrolled in a cluster-randomized trial assessing the effects of growth charts and small-quantity lipid-based nutrient supplements on linear growth. Samples were analyzed using the 11-plex Micronutrient and EED Assessment Tool, which incorporates 2 biomarkers of EED, namely intestinal fatty acid-binding protein (I-FABP), a marker of epithelial damage, and soluble CD14 (sCD14), a marker of microbial translocation. Associations between log2-transformed biomarker concentrations and anthropometric (height-for-age z-score [HAZ], weight-for-height z-score, and weight-for-age z-score) and developmental (Global Scales of Early Development development for age z-score and saccadic reaction time [SRT]) outcomes were assessed using linear regression analyses adjusted for background characteristics.

RESULTS

Mean ± SD HAZ was -1.94 ± 1.10. Higher sCD14 and I-FABP concentrations were significantly associated with lower HAZ (β: -0.21, 95% CI: -0.41, -0.01 and β: -0.20, 95% CI: -0.32, -0.08, respectively). Higher I-FABP concentrations were significantly associated with lower development-for-age z-score (β: -0.22, 95% CI: -0.40, -0.03) and slower SRT (β: 7.37 ms, 95% CI: 2.02, 12.72) as were higher alpha-1-acid glycoprotein concentrations (HAZ β: -0.38, 95% CI: -0.72, -0.03; SRT β: 11.14 ms, 95% CI: 0.94, 21.72).

CONCLUSIONS

In children in Lusaka, biomarkers of EED were associated with poor anthropometric and developmental outcomes, underscoring the need for interventions to address EED to improve child health globally.

CLINICAL TRIAL REGISTRY

ClinicalTrials.gov identifier for parent trial: NCT05120427. https://clinicaltrials.gov/ct2/show/NCT05120427.

Role of infant and early-childhood nutrition on gut inflammation, stunting, growth, and development in the African context: A narrative review

This article synthesizes the existing research evidence from Tanzania, a low- to middle-income country, highlighting the persistent issue of growth stunting. Stunting begins early in life, potentially even in utero. It is becoming increasingly clear that infant and childhood environmental enteric dysfunction plays a significant role in perpetuating the observed stunting. The repercussions of this condition include poor growth and detrimental effects on neurodevelopment, preventing affected children from reaching their full potential. The economic implications of this are substantial. The manuscript outlines the trajectory from low birth weight and suboptimal lactation to altered weaning practices and changes in the gut microbiome. It also presents current perspectives on how to mitigate these adverse effects, with a focus on early interventions in lactation and feeding during the crucial first 1000 days of life.

Campylobacter colonization and undernutrition in infants in rural eastern Ethiopia - a longitudinal community-based birth cohort study

Background

Campylobacter is associated with environmental enteric dysfunction (EED) and malnutrition in children. Campylobacter infection could be a linchpin between livestock fecal exposure and health outcomes in low-resource smallholder settings.

Methods

We followed a birth cohort of 106 infants in rural smallholder households in eastern Ethiopia up to 13 months of age. We measured anthropometry, surveyed sociodemographic determinants, and collected stool and urine samples. A short survey was conducted during monthly visits, infant stool samples were collected, and Campylobacter spp. was quantified using genus-specific qPCR. In month 13, we collected stool and urine samples to assay for EED biomarkers. We employed regression analyses to assess the associations of household determinants with Campylobacter colonization, EED, and growth faltering.

Results

The Campylobacter load in infant stools increased with age. The mean length-for-age Z-score (LAZ) decreased from -0.45 at 3-4 months of age to -2.06 at 13 months, while the prevalence of stunting increased from 3 to 51%. The prevalence of EED at 13 months of age was 56%. A higher Campylobacter load was associated with more frequent diarrhea. Prelacteal feeding significantly increased Campylobacter load in the first month of life. Over the whole follow-up period, Campylobacter load was increased by keeping chickens unconfined at home and unsanitary disposal of infant stools while decreased by mothers' handwashing with soap. Longitudinally, Campylobacter load was positively associated with food insecurity, introduction of complementary foods, and raw milk consumption. There were no significant associations between Campylobacter load, EED, and LAZ.

Conclusion

This study found that most determinants associated with increased Campylobacter infection were related to suboptimal feeding practices and hygiene. The findings related to livestock-associated risks were inconclusive. Although stunting, EED, and Campylobacter prevalence rates all increased to high levels by the end of the first year of life, no significant association between them was identified. While additional research is needed to investigate whether findings from this study are replicable in other populations, community efforts to improve infant and young child feeding practices and food hygiene, and water, sanitation, and hygiene (WaSH) at the household level, could reduce (cross-)contamination at the point of exposure.

Harnessing the power of probiotics to enhance neuroplasticity for neurodevelopment and cognitive function in stunting: a comprehensive review

BACKGROUND

Stunting become a global concern because it's not only affecting physical stature, but also affecting on neurodevelopment and cognitive function. These impacts are resulting in long-term consequences especially for human resources, such as poor-quality labor, decreased productivity due to decreasing of health quality, including immunity and cognitive aspect.

DISCUSSION

This comprehensive review found that based on many studies, there is an altered gut microbiota, or dysbiosis, in stunted children, causing the impairment of brain development through Microbiota-Gut Brain Axis (MGB Axis) mechanism. The administration of probiotics has been known affect MGBA by improving the physical and chemical gut barrier integrity, producing antimicrobial substance to inhibit pathogen, and recovering the healthy gut microbiota. Probiotics, along with healthy gut microbiota, produce SCFAs which have various positive impact on CNS, such as increase neurogenesis, support the development and function of microglia, reduce inflammatory signaling, improve the Blood Brain Barrier's (BBB's) integrity, produce neurotropic factors (e.g. BDNF, GDNF), and promote the formation of new synapse. Probiotics also could induce the production of IGF-1 by intestinal epithelial cells, which functioned as growth factor of multiple body tissues and resulted in improvement of linear growth as well as brain development.

CONCLUSION

These properties of probiotics made it become the promising and feasible new treatment approach for stunting. But since most of the studies in this field are conducted in animal models, it is necessary to translate animal data into human models and do additional study to identify the numerous components in the MGB axis and the effect of probiotics on human.

Associations between dietary patterns and intestinal inflammation among HIV-infected and uninfected adults: A cross-sectional study in Tanzania

The increased burden of non-communicable diseases (NCDs) is fueled by lifestyle factors including diet. This cross-sectional study explored among Tanzanian adults whether unhealthy dietary patterns are associated with intestinal and systemic inflammation which could increase the risk of NCDs. The study included 574 participants, with both diet and inflammatory markers data. Dietary patterns were derived using principal component analysis and reduced rank regression, revealing three main patterns: vegetable-rich, vegetable-poor, and carbohydrate-dense diets. Fecal myeloperoxidase (MPO) and neopterin (NEO) were markers of intestinal inflammation whereas plasma lipopolysaccharide-binding protein (LBP) and C-reactive protein (CRP) were assessed as markers of systemic inflammation. Ordinal logistic regression was used to assess associations between terciles of dietary patterns and quintiles of the inflammatory markers adjusting for potential confounders. High adherence to a vegetable-poor dietary pattern was associated with elevated MPO (adjusted OR, 1.7 95% CI 1.1, 2.8). NEO tended to be higher in people with high adherence to both vegetable-poor pattern (adjusted OR, 2.6 95% CI 1.0, 6.4) and vegetable-rich pattern (adjusted OR, 2.7, 95% CI 1.1, 6.5). No associations were found between dietary patterns and systemic inflammation markers (LBP and CRP). We found links between dietary vegetable intake and intestinal inflammation but not systemic inflammation. However, the cross-sectional nature of the study limits establishing causality and the sample size for some variables may have been inadequate, emphasizing the need for further studies to understand how dietary habits influence inflammation in this population.

Iron-rich food consumption and predictors among children aged 6-59 months old in Ethiopia using 2005-2016 national representative data

Children who do not consume enough iron have decreased growth, reduced immunity, and poor cognitive development. This study aimed to assess the pooled iron-rich food consumption, trends, and predictors among children aged 6-59 months old in Ethiopia. This study used Ethiopian demographic and health survey (EDHS-2005-2016) data with a total weighted sample size of 26,773 among children aged 6-59 months old. A multilevel mixed-effects logistic regression analysis was used to identify predictors of good iron-rich food consumption. The pooled proportion of iron-rich food consumed among children aged 6-59 months in Ethiopia was 11.77% (10.71, 12.92%). In Ethiopia, the proportion of iron-rich food intake by children aged 6-59 months was slightly increased from 9.25% (8.04, 10.62%) in EDHS 2005 to 10.86% (9.06, 12.95%) in EDHS 2011, and sharply increased to 17.49% (15.04, 20.24%) in EDHS 2016. The findings indicated that being children born to mothers aged 20 to 34 years old [AOR = 0.56, 95% CI: 0.35, 0.89], mothers aged ≥ 35 years old [AOR = 0.47, 95% CI: 0.28, 0.82], married parents [AOR = 1.68, 95% CI: 1.14, 2.48], completed primary education [AOR = 1.32, 95% CI: 1.02, 1.73], secondary education [AOR = 2.66, 95% CI: 1.53, 4.59], a higher education status of mother [AOR = 3.98, 95% CI: 1.92, 8.23], medium family [AOR = 1.39, 95% CI: 1.03, 1.89], rich family [AOR = 1.45, 95% CI: 1.09, 1.95], media exposure [AOR = 1.35, 95% CI: 1.06, 1.72], residents of the Tigray [AOR = 2.69, 95% CI: 1.51, 4.79], Oromia [AOR = 3.30, 95% CI: 1.30, 4.02], Benishangul [AOR = 2.12, 95% CI: 1.15, 3.88], Gambela [AOR = 5.85, 95% CI: 2.97, 11.50], and Dire Dawa region [AOR = 3.38, 95% CI: 1.76, 6.47], were significantly associated with good iron-rich food consumption among children aged 6-59 months old. The findings revealed that iron-rich food intake was considerably low among Ethiopian children aged 6-59 months. Increasing women's literacy and economic empowerment improves iron-rich food consumption among children aged 6-59 months old.

Gastrointestinal and respiratory morbidity when introducing eggs as complementary food: a randomised controlled trial in South African infants

We investigated the incidence and duration of morbidity symptoms among infants aged 6 to 9 months from a low socioeconomic community receiving one egg daily for 6 months. This was a secondary outcome of a randomised controlled trial (RCT) of 500 infants conducted in Jouberton, South Africa. The primary outcome was linear growth. Morbidity data were collected weekly using a symptoms diary and qualitative data with focus group discussions at the endpoint. Ethical approval was obtained from the North-West University Health Research Ethics Committee. The intervention group had a ~ 5% higher incidence of gastrointestinal morbidity (17.0%) compared to the control group (11.9%). Gastrointestinal morbidity without fever tended to be 1.4 times higher in the intervention group (OR: 1.43, 95% CI: 1.03, 1.93; P = 0.058) and tended to be 4 times higher with fever (OR: 4.07, 95% CI: 0.86, 19.23; P = 0.077). The duration of total gastrointestinal and respiratory morbidity was 1.5 days longer in the intervention group (β: 1.491; 95% CI 0.064, 2.918; P = 0.041). Complementary feeding with eggs may have contributed towards an increased risk for gastrointestinal morbidity.

Open defecation among Kenyan households: an analysis of demographic and health survey 2022 and census report of 2019

BACKGROUND

Open defecation (OD) is the disposal of human excreta in the fields, bushes, water bodies and other open spaces. It poses a public health risk as it can lead to the spread of diarrhoea, cholera, soil-transmitted helminths and trachoma. Kenya aims to achieve 100% open defecation free status by 2030 in line with Sustainable development goal number 6. This study sought to determine factors influencing OD at the household level as well as quantify the number of households practicing OD in each of the 47 Kenyan counties.

METHODS

Data from the household questionnaire of the Kenya Demographic and Health Survey, 2022 was analysed. Bivariate logistic regression was done with open defecation status as the dependent variable. Independent variables were poverty status, place of residence, ownership of farm animals, gender and educational level of household head. The number of households practicing OD per county were determined using the Kenya Census report of 2019.

RESULTS

Poverty was the strongest predictor of a household practicing OD (OR 43.8 95% CI 26.1-73.8) followed by educational status of the household head (OR 3.3 95% CI 2.3-4.6 ) and the household not owning livestock ( OR 0.7 95% CI 0.6-0.9). An estimated 7.4% of households practice OD. These are estimated to be 814,223 households. Out of these, 686,051 households (84.3%) are found in the 15 counties ranked as having a high population practicing OD. Five counties have managed to eliminate OD and another nine have OD rates of less than 0.5%.

CONCLUSION

Kenya has made commendable progress in eliminating OD. Poverty is a significant predictor of OD at the household level. To eliminate OD, it is advised that more efforts be targeted towards poor households as well as the 15 counties having a high number of OD-practicing households.

Dietary aflatoxins exposure, environmental enteropathy, and their relation with childhood stunting

Childhood stunting is a global phenomenon affecting more than 149 million children under the age of 5 worldwide. Exposure to aflatoxins (AFs) in utero, during breastfeeding, and consumption of contaminated food affect the gut microbiome, resulting in intestinal dysfunction and potentially contributing to stunting. This review explores the potential relationship between AF exposure, environmental enteropathy and childhood stunting. AFs bind to DNA, disrupt protein synthesis and elicit environmental enteropathy (EE). An EE alters the structure of intestinal epithelial cells, impairs nutrient uptake and leads to malabsorption. This article proposes possible intervention strategies for researchers and policymakers to reduce AF exposure, EE and childhood stunting, such as exposure reduction, the implementation of good agricultural practices, dietary diversification and improving environmental water sanitation and hygiene.

Malnutrition enteropathy in Zambian and Zimbabwean children with severe acute malnutrition: A multi-arm randomized phase II trial

Malnutrition underlies almost half of all child deaths globally. Severe Acute Malnutrition (SAM) carries unacceptable mortality, particularly if accompanied by infection or medical complications, including enteropathy. We evaluated four interventions for malnutrition enteropathy in a multi-centre phase II multi-arm trial in Zambia and Zimbabwe and completed in 2021. The purpose of this trial was to identify therapies which could be taken forward into phase III trials. Children of either sex were eligible for inclusion if aged 6-59 months and hospitalised with SAM (using WHO definitions: WLZ <-3, and/or MUAC <11.5 cm, and/or bilateral pedal oedema), with written, informed consent from the primary caregiver. We randomised 125 children hospitalised with complicated SAM to 14 days treatment with (i) bovine colostrum (n = 25), (ii) N-acetyl glucosamine (n = 24), (iii) subcutaneous teduglutide (n = 26), (iv) budesonide (n = 25) or (v) standard care only (n = 25). The primary endpoint was a composite of faecal biomarkers (myeloperoxidase, neopterin, α1-antitrypsin). Laboratory assessments, but not treatments, were blinded. Per-protocol analysis used ANCOVA, adjusted for baseline biomarker value, sex, oedema, HIV status, diarrhoea, weight-for-length Z-score, and study site, with pre-specified significance of P < 0.10. Of 143 children screened, 125 were randomised. Teduglutide reduced the primary endpoint of biomarkers of mucosal damage (effect size -0.89 (90% CI: -1.69,-0.10) P = 0.07), while colostrum (-0.58 (-1.4, 0.23) P = 0.24), N-acetyl glucosamine (-0.20 (-1.01, 0.60) P = 0.67), and budesonide (-0.50 (-1.33, 0.33) P = 0.32) had no significant effect. All interventions proved safe. This work suggests that treatment of enteropathy may be beneficial in children with complicated malnutrition. The trial was registered at ClinicalTrials.gov with the identifier NCT03716115.

A Model-Based 13C-Sucrose Breath Test Diagnostic for Gut Function Disorders Characterized by a Loss of Sucrase-Isomaltase Enzymatic Activity

BACKGROUND

Environmental enteric dysfunction (EED) causes malnutrition in children in low-resource settings. Stable-isotope breath tests have been proposed as noninvasive tests of altered nutrient metabolism and absorption in EED, but uncertainty over interpreting the breath curves has limited their use. The activity of sucrose-isomaltase, the glucosidase enzyme responsible for sucrose hydrolysis, may be reduced in EED. We previously developed a mechanistic model describing the dynamics of the 13C-sucrose breath test (13C-SBT) as a function of underlying metabolic processes.

OBJECTIVES

This study aimed to determine which breath test curve dynamics are associated with sucrose hydrolysis and with the transport and metabolism of the fructose and glucose moieties and to propose and evaluate a model-based diagnostic for the loss of activity of sucrase-isomaltase.

METHODS

We applied the mechanistic model to 2 sets of exploratory 13C-SBT experiments in healthy adult participants. First, 19 participants received differently labeled sucrose tracers (U-13C fructose, U-13C glucose, and U-13C sucrose) in a crossover study. Second, 16 participants received a sucrose tracer accompanied by 0, 100, and 750 mg of Reducose, a sucrase-isomaltase inhibitor. We evaluated a model-based diagnostic distinguishing between inhibitor concentrations using receiver operator curves, comparing with conventional statistics.

RESULTS

Sucrose hydrolysis and the transport and metabolism of the fructose and glucose moieties were reflected in the same mechanistic process. The model distinguishes these processes from the fraction of tracer exhaled and an exponential metabolic process. The model-based diagnostic performed as well as the conventional summary statistics in distinguishing between no and low inhibition [area under the curve (AUC): 0.77 vs. 0.66-0.79] and for low vs. high inhibition (AUC 0.92 vs. 0.91-0.99).

CONCLUSIONS

Current summary approaches to interpreting 13C breath test curves may be limited to identifying only gross gut dysfunction. A mechanistic model-based approach improved interpretation of breath test curves characterizing sucrose metabolism.

Small Intestine Bacterial Overgrowth is associated with increased Campylobacter and epithelial injury in duodenal biopsies of Bangladeshi children

Small intestine bacterial overgrowth (SIBO) has been associated with enteric inflammation, linear growth stunting, and neurodevelopmental delays in children from low-income countries. Little is known about the histologic changes or epithelial adherent microbiota associated with SIBO. We sought to describe these relationships in a cohort of impoverished Bangladeshi children. Undernourished 12-18-month-old children underwent both glucose hydrogen breath testing for SIBO and duodenoscopy with biopsy. Biopsy samples were subject to both histological scoring and 16s rRNA sequencing. 118 children were enrolled with 16s sequencing data available on 53. Of 11 histological features, we found that SIBO was associated with one, enterocyte injury in the second part of the duodenum (R = 0.21, p = 0.02). SIBO was also associated with a significant increase in Campylobacter by 16s rRNA analysis (Log 2-fold change of 4.43; adjusted p = 1.9 x 10-6). These findings support the growing body of literature showing an association between SIBO and enteric inflammation and enterocyte injury and further delineate the subgroup of children with environmental enteric dysfunction who have SIBO. Further, they show a novel association between SIBO and Campylobacter. Mechanistic work is needed to understand the relationship between SIBO, enterocyte injury, and Campylobacter.

Assessment of the role of gut health in childhood stunting in a multisite, longitudinal study in India, Indonesia and Senegal: a UKRI GCRF Action Against Stunting Hub protocol

INTRODUCTION

Childhood stunting has a complex aetiology, with poor gut health being an important contributor. This study will assess inter-relationships between maternal and infant gut health indices and infant linear growth. Inter-relationships between gut health indices, systemic inflammation and growth hormones in early childhood will also be assessed.

METHODS AND ANALYSIS

A longitudinal observational study of cohorts of 600 newborns and their mothers in India, Indonesia and Senegal will be conducted. Women will be recruited during pregnancy and their children followed up to age 24 months. Stool, urine and blood samples will be collected from the women and children for assessments of helminthic and protozoal parasites, bacterial pathogens, faecal microbiota taxa, biomarkers of environmental enteric dysfunction, systemic inflammation and growth hormones. Child anthropometric measurements will be collected at birth and at ages 3, 6, 9, 12, 18 and 24 months. The gut health indices will be integrated with cohort data from other Action Against Stunting Hub (AASH) workstreams for interdisciplinary analyses of childhood stunting and the development of a new typology of stunting.

DISCUSSION

This study will advance scientific understanding of the role of gut health in childhood stunting and will contribute to a broader knowledge of the complex aetiology of this condition as part of the interdisciplinary AASH research to reduce the global burden of childhood stunting.

ETHICS AND DISSEMINATION

This study has been approved by the relevant Ethics Committees in Senegal, India, and Indonesia and LSHTM. The results will be submitted for publication in peer-reviewed journals.

Pilot Study of Heat-Stabilized Rice Bran Acceptability in Households of Rural Southwest Guatemala and Estimates of Fiber, Protein, and Micro-Nutrient Intakes among Mothers and Children

Nutrient-dense, acceptable foods are needed in low-resource settings. Rice bran, a global staple byproduct of white rice processing, is rich in amino acids, fibers, and vitamins, when compared to other cereal brans. This pilot study examines the nutritional contribution of rice bran to the daily diets of mother-child pairs in rural southwest Guatemala. Thirty households were screened. Mothers (≥18 years) and children (6 to 24 months) completed 24 h dietary recalls at baseline and after 12 weeks (endline) for diet intake and diversity analyses. During biweekly visits for 12 weeks, households with <5 members received 14 packets containing 60 g of heat-stabilized rice bran, and those with ≥5 members received 28 packets. The macro- and micro-nutrient contributions of rice bran and whole, cooked black beans were included in dietary simulation models with average intakes established between the recalls and for comparison with dietary reference intakes (DRIs). A baseline child food frequency questionnaire was administered. The 27 mothers and 23 children with complete recalls were included in analyses. Daily maternal consumption of 10 g/d of rice bran plus 100 g/d of black beans resulted in all achieving at least 50% of the fiber, protein, magnesium, niacin, potassium, and thiamin DRIs. Daily child consumption of 3 g/d of rice bran plus 10 g/d of black beans resulted in all achieving at least 50% of the magnesium, niacin, phosphorous, and thiamine DRIs. For 15/17 food categories, male children had a higher intake frequency, notably for animal-source foods and coffee. Dietary rice bran coupled with black beans could improve nutritional adequacy, especially for fiber and key micro-nutrients, with broader implications for addressing maternal and child malnutrition in low-resource settings.

Transcutaneous fluorescence spectroscopy: development and characterization of a compact, portable, and fiber-optic sensor

Significance

The integrity of the intestinal barrier is gaining recognition as a significant contributor to various pathophysiological conditions, including inflammatory bowel disease, celiac disease, environmental enteric dysfunction (EED), and malnutrition. EED, for example, manifests as complex structural and functional changes in the small intestine leading to increased intestinal permeability, inflammation, and reduced absorption of nutrients. Despite the importance of gut function, current techniques to assess intestinal permeability (such as endoscopic biopsies or dual sugar assays) are either highly invasive, unreliable, and/or difficult to perform in certain patient populations (e.g., infants).

Aim

We present a portable, optical sensor based on transcutaneous fluorescence spectroscopy to assess gut function (in particular, intestinal permeability) in a fast and noninvasive manner.

Approach

Participants receive an oral dose of a fluorescent contrast agent, and a wearable fiber-optic probe detects the permeation of the contrast agent from the gut into the blood stream by measuring the fluorescence intensity noninvasively at the fingertip. We characterized the performance of our compact optical sensor by comparing it against an existing benchtop spectroscopic system. In addition, we report results from a human study in healthy volunteers investigating the impact of skin tone and contrast agent dose on transcutaneous fluorescence signals.

Results

The first study with eight healthy participants showed good correlation between our compact sensor and the existing benchtop spectroscopic system [correlation coefficient ( r ) > 0.919 , p < 0.001 ]. Further experiments in 14 healthy participants revealed an approximately linear relationship between the ingested contrast agent dose and the collected signal intensity. Finally, a parallel study on the impact of different skin tones showed no significant differences in signal levels between participants with different skin tones (p > 0.05 ).

Conclusions

In this paper, we demonstrate the potential of our compact transcutaneous fluorescence sensor for noninvasive monitoring of intestinal health.

Effect of Gut Microbiota-Directed Complementary Food Supplementation on Fecal and Plasma Biomarkers of Gut Health and Environmental Enteric Dysfunction in Slum-Dwelling Children with Moderate Acute Malnutrition

Dietary supplementation with a gut microbiota-directed complementary food (MDCF-2) significantly improved weight gain and repaired gut microbiota, as reported in a recent randomized controlled trial on Bangladeshi children with moderate acute malnutrition (MAM). Environmental enteric dysfunction (EED) is a small bowel disorder, and recent evidence shows that it is linked to growth failure in children. Therefore, we intended to investigate whether supplementation with MDCF-2 has any role in modifying gut health by changing the levels of biomarkers of EED and gut inflammation in children with MAM. We randomly assigned 124 children aged 12-18 months to one of two intervention diets, either MDCF-2 or ready-to-use supplementary food (RUSF). Approximately 50 g of the diet was administered in two feeding sessions daily for 12 weeks. Stool and plasma biomarkers were assessed to evaluate intestinal health. Results showed that the average change in citrulline concentration (µmol/L) significantly increased among children who consumed MDCF-2 compared to those who consumed RUSF (mean difference-in-differences: 123.10; 95% CI: 3.60, 242.61; p = 0.044). The research findings demonstrated that MDCF-2 might have a beneficial effect on improving the gastrointestinal health of malnourished children.

NAD+ precursors and bile acid sequestration treat preclinical refractory environmental enteric dysfunction

Environmental enteric dysfunction (EED) is a diffuse small bowel disorder associated with poor growth, inadequate responses to oral vaccines, and nutrient malabsorption in millions of children worldwide. We identify loss of the small intestinal Paneth and goblet cells that are critical for innate immunity, reduced villous height, increased bile acids, and dysregulated nicotinamide adenine dinucleotide (NAD+) synthesis signaling as potential mechanisms underlying EED and which also correlated with diminished length-for-age z score. Isocaloric low-protein diet (LPD) consumption in mice recapitulated EED histopathology and transcriptomic changes in a microbiota-independent manner, as well as increases in serum and fecal bile acids. Children with refractory EED harbor single-nucleotide polymorphisms in key enzymes involved in NAD+ synthesis. In mice, deletion of Nampt, the gene encoding the rate-limiting enzyme in the NAD+ salvage pathway, from intestinal epithelium also reduced Paneth cell function, a deficiency that was further aggravated by LPD. Separate supplementation with NAD+ precursors or bile acid sequestrant partially restored LPD-associated Paneth cell defects and, when combined, fully restored all histopathology defects in LPD-fed mice. Therapeutic regimens that increase protein and NAD+ contents while reducing excessive bile acids may benefit children with refractory EED.

Opportunities to Interrupt Transmission of Enteropathogens of Poultry Origin in Maputo, Mozambique: A Transmission Model Analysis

BACKGROUND

The burden of diarrheal diseases remains high among children in low-income countries. Enteropathogens are challenging to control because they are transmitted via multiple pathways. Chickens are an important animal protein source, but live chickens and their products are often highly contaminated with enteropathogens.

OBJECTIVES

We conducted this study to a) understand the contribution of multiple transmission pathways to the force of infection of Campylobacter spp. and nontyphoidal Salmonella spp., b) quantify the potential impact of reducing each pathway on human infection, and c) quantify hypothesized pathway reduction from the context of Maputo, Mozambique.

METHODS

We developed transmission models for Campylobacter and Salmonella that captured person-to-person, water-to-person, food-to-person, soil-to-person, animal-to-person, and all-other-sources-to-person in an urban, low-income setting in Mozambique. We calibrated these models using prevalence data from Maputo, Mozambique and estimates of attributable fraction of transmission pathways for the region. We simulated the prevalence of human infection after reducing transmission through each pathway.

RESULTS

Simulation results indicated that if foodborne transmission were reduced by 90%, the prevalence of Campylobacter and Salmonella infection would decline by [52.2%; 95% credible interval (CrI): 39.7, 63.8] and (46.9%; 95% CrI: 39, 55.4), respectively. Interruption of any other pathway did not have a substantial impact. Combined with survey and microbiology data, if contamination of broiler chicken meat at informal markets in Maputo could be reduced by 90%, the total infection of Campylobacter and Salmonella could be reduced by 21% (16-26%) and 12% (10-13%), respectively.

DISCUSSION

Our transmission models showed that the foodborne transmission has to be reduced to control enteropathogen infections in our study site, and likely in other similar contexts, but mitigation of this transmission pathway has not received sufficient attention. Our model can serve as a tool to identify effective mitigation opportunities to control zoonotic enteropathogens. https://doi.org/10.1289/EHP12314.

A scoping review: urinary markers of metabolic maturation in infants with CHD and the relationship to growth

BACKGROUND

Growth failure in infants born with CHD is a persistent problem, even in those provided with adequate nutrition.

OBJECTIVE

To summarise the published data describing the change in urinary metabolites during metabolic maturation in infants with CHD and identify pathways amenable to therapeutic intervention.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Studies using qualitative or quantitative methods to describe urinary metabolites pre- and post-cardiac surgery and the relationship with growth in infants with CHD.

SOURCES OF EVIDENCE

NICE Healthcare Databases website was used as a tool for multiple searches.

RESULTS

347 records were identified, of which 37 were duplicates. Following the removal of duplicate records, 310 record abstracts and titles were screened for inclusion. The full texts of eight articles were reviewed for eligibility, of which only two related to infants with CHD. The studies included in the scoping review described urinary metabolites in 42 infants. A content analysis identified two overarching themes of metabolic variation predictive of neurodevelopmental abnormalities associated with anaerobic metabolism and metabolic signature associated with the impact on gut microbiota, inflammation, energy, and lipid digestion.

CONCLUSION

The results of this scoping review suggest that there are considerable gaps in our knowledge relating to metabolic maturation of infants with CHD, especially with respect to growth. Surgery is a key early life feature for CHD infants and has an impact on the developing biochemical phenotype with implications for metabolic pathways involved in immunomodulation, energy, gut microbial, and lipid metabolism. These early life fingerprints may predict those individuals at risk for neurodevelopmental abnormalities.

Genetic variation in environmental enteropathy and stunting in Zambian children: A pilot genome wide association study using the H3Africa chip

PURPOSE

Stunting is known to be heavily influenced by environmental factors, so the genetic contribution has received little attention. Here we report an exploration of genetic influences in stunted Zambian children with environmental enteropathy.

METHOD

Children with stunting (LAZ < -2) were enrolled and given nutritional therapy. Those that were non-responsive to therapy were designated as cases, and children with good growth (LAZ > -1) from the same community as controls. Blood and stool samples were taken to measure biomarkers of intestinal inflammation, epithelial damage, and microbial translocation. Single nucleotide polymorphism array genotyping was carried out on saliva samples using the H3Africa consortium array.

RESULTS

Genome wide associations were analysed in 117 cases and 41 controls. While no significant associations with stunting were observed at P<5x10-8, likely due to the small sample size, interesting associations were observed at lower thresholds. SNPs associated with stunting were in genomic regions known to modulate neuronal differentiation and fatty acid biosynthesis. SNPs associated with increased microbial translocation were associated with non-integrin membrane ECM interactions, tight junctions, hemostasis, and G-alpha signalling events. SNPs associated with increased inflammation were associated with, ECM interactions, purine metabolism, axon guidance, and cell motility. SNPs negatively associated with inflammation overlapped genes involved in semaphoring interactions. We explored the existing coeliac disease risk HLA genotypes and found present: DQ2.5 (7.5%), DQ8 (3.5%) and DQ2.2 (3.8%); however, no children were positive for coeliac antibodies. We detected HLA-DRB:1301 and HLA-C:1802 with high odds ratios and P<0.05 in stunted children compared to controls.

CONCLUSION

Genetic variations associated with stunting and the enteropathy underlying it, include variants associated with multiple pathways relating to gene expression, glycosylation, nerve signalling, and sensing of the nutritional and microbiological milieu.

Immune modulation by nutritional intervention in malnourished children: Identifying the phenotypic distribution and functional responses of peripheral blood mononuclear cells

Malnourished children are susceptible to an increased risk of mortality owing to impaired immune functions. However, the underlying mechanism of altered immune functions and its interaction with malnutrition is poorly understood. This study investigates the immune function and evaluates the effect of a particular nutritional intervention on the immune cells of undernourished children. Stunted (LAZ <-2) and at-risk of being stunted (length-for-age Z-scores, LAZ <-1 to -2) children aged between 12 and 18 months were enrolled and were provided with the daily nutritional intervention of one egg and 150 mL cow's milk for 90 days. Peripheral blood mononuclear cells (PBMCs) were isolated at enrolment and upon completion of the intervention. Phenotypic profiles for CD3+ cells, CD4+ cells, CD8+ cells, NKT cells, and B cells were similar in both cohorts, both before and after the intervention. However, activated B cells (CD25+) were increased after nutritional intervention in the at-risk of being stunted cohort. Several pro-inflammatory cytokines, IL-6, IFN-γ, and TNF-α, were elevated in the stunted children following the nutritional intervention. The results of the study indicate that nutritional intervention may have a role on activated B cells (CD25+) s in children who are at-risk of being stunted and may alter the capacity of PBMC to produce inflammatory cytokines in stunted children.

Exploring Factors Associated with Stunting in 6-Month-Old Children: A Population-Based Cohort Study in Sulawesi, Indonesia

Stunting in children under the age of two is a significant global concern, particularly in low- and middle-income countries like Indonesia. Intervention efforts often come too late as many of the underlying causal factors have already occurred earlier. While antenatal multiple micronutrient supplements (MMS) have demonstrated positive effects on pregnancy outcomes, their impact on infant growth in the first six months remains inadequately explored in epidemiological studies. This study aims to identify factors associated with stunting at six months in infants whose mothers received MMS. A population-based cohort study was conducted in four subdistricts of Banggai, Indonesia. Pregnant women were recruited in their third trimester and followed up until their children were six months of age. Validated questionnaires were employed to gather data on social determinants of health and diet, and standardised methods were utilised for anthropometric measurements. Stunting was determined based on the WHO child growth standards. The analysis comprised data from 152 mother-child pairs. The prevalence of stunting during early infancy (first two months) was 18.4%, which decreased to 15.8% in later infancy (at six months). Factors such as small-for-gestational-age (AOR = 11.29; 2.73-46.66), preterm birth (AOR = 6.33; 1.25-31.97), short birth length (AOR = 4.31; 1.11-16.78), maternal mid-upper arm circumference (MUAC) below 23.5 cm, and female infants (AOR = 3.27; 95%CI: 1.04-10.27) were associated with stunting at six months. This study highlights that stunting in the first six months is present at birth, with small-for-gestational-age (SGA) as a strong predictor. In addition, there was a trend to improved growth (-0.30 [-0.79 to 0.18]) in infants born to mothers who received MMS supplementation pre-pregnancy rather than during pregnancy, although it was not statistically significant.

Mechanistic inference of the metabolic rates underlying 13 C breath test curves

Carbon stable isotope breath tests offer new opportunities to better understand gastrointestinal function in health and disease. However, it is often not clear how to isolate information about a gastrointestinal or metabolic process of interest from a breath test curve, and it is generally unknown how well summary statistics from empirical curve fitting correlate with underlying biological rates. We developed a framework that can be used to make mechanistic inference about the metabolic rates underlying a 13C breath test curve, and we applied it to a pilot study of 13C-sucrose breath test in 20 healthy adults. Starting from a standard conceptual model of sucrose metabolism, we determined the structural and practical identifiability of the model, using algebra and profile likelihoods, respectively, and we used these results to develop a reduced, identifiable model as a function of a gamma-distributed process; a slower, rate-limiting process; and a scaling term related to the fraction of the substrate that is exhaled as opposed to sequestered or excreted through urine. We demonstrated how the identifiable model parameters impacted curve dynamics and how these parameters correlated with commonly used breath test summary measures. Our work develops a better understanding of how the underlying biological processes impact different aspect of 13C breath test curves, enhancing the clinical and research potential of these 13C breath tests.

Assessing environmental enteric dysfunction via multiplex assay and its relation to growth and development among HIV-exposed uninfected Tanzanian infants

BACKGROUND

Environmental enteric dysfunction (EED) may contribute to poor growth and development in young children. While validated EED biomarkers are currently lacking, multiplex assays are able to capture multiple domains of the condition. The purpose of this exploratory study was to examine the relationship between biomarkers of EED and subsequent growth and development among Tanzanian HIV-exposed uninfected (HEU) infants.

METHODOLOGY

We enrolled 467 infants of mothers living with HIV who had participated in a trial of vitamin D3 supplementation during pregnancy. Infant serum samples collected at 6 weeks (n = 365) and 6 months (n = 266) were analyzed for anti-flagellin and anti-lipopolysaccharide (LPS) IgA and IgG via ELISA as well as the 11-plex Micronutrient and EED Assessment Tool (MEEDAT), which incorporates two biomarkers of EED [intestinal fatty acid-binding protein (I-FABP) and soluble CD14 (sCD14)]. Outcomes were 12-month growth [length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and weight-for-age z-score (WAZ)] and development [Caregiver Reported Early Development Instruments (CREDI) z-scores] and were assessed using linear regression.

FINDINGS

In primary analyses, higher quartiles of 6-month anti-LPS IgG concentrations were significantly associated with lower LAZ at 12 months (ptrend = 0.040). In secondary analyses, higher log2-transformed 6-week anti-flagellin IgA and 6-month anti-LPS IgA concentrations were significantly associated with lower LAZ at 12 months. No associations were observed between I-FABP or sCD14 and infant growth. However, higher log2-transformed 6-week sCD14 concentrations were significantly associated with lower overall CREDI z-scores, while higher log2-transformed 6-month I-FABP concentrations were significantly associated with higher overall CREDI z-scores.

CONCLUSIONS

Unlike anti-flagellin and anti-LPS Igs, MEEDAT's biomarkers of EED (I-FABP and sCD14) were not associated with subsequent linear growth among HEU infants in Tanzania. The relationship between EED and infant development warrants further study.

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

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

Microbe-mediated intestinal NOD2 stimulation improves linear growth of undernourished infant mice

The intestinal microbiota is known to influence postnatal growth. We previously found that a strain of Lactiplantibacillus plantarum (strain LpWJL) buffers the adverse effects of chronic undernutrition on the growth of juvenile germ-free mice. Here, we report that LpWJL sustains the postnatal growth of malnourished conventional animals and supports both insulin-like growth factor-1 (IGF-1) and insulin production and activity. We have identified cell walls isolated from LpWJL, as well as muramyl dipeptide and mifamurtide, as sufficient cues to stimulate animal growth despite undernutrition. Further, we found that NOD2 is necessary in intestinal epithelial cells for LpWJL-mediated IGF-1 production and for postnatal growth promotion in malnourished conventional animals. These findings indicate that, coupled with renutrition, bacteria cell walls or purified NOD2 ligands have the potential to alleviate stunting.

Citrulline and kynurenine to tryptophan ratio: potential EED (environmental enteric dysfunction) biomarkers in acute watery diarrhea among children in Bangladesh

Two emerging biomarkers of environmental enteric dysfunction (EED) include plasma citrulline (CIT), and the kynurenine (KYN): tryptophan (TRP)/ (KT) ratio. We sought to investigate the plasma concentration of CIT and KT ratio among the children having dehydrating diarrhea and examine associations between concentrations of CIT and KT ratio with concurrent factors. For this analysis, we used cross-sectional data from a total of 102, 6-36 months old male children who suffered from non-cholera acute watery diarrhea and had some dehydration admitted to an urban diarrheal hospital, in Bangladesh. CIT, TRP, and KYN concentrations were determined at enrollment from plasma samples using ELIZA. At enrollment, the mean plasma CIT concentration was 864.48 ± 388.55 µmol/L. The mean plasma kynurenine, tryptophan concentrations, and the KT ratio (× 1000) were 6.93 ± 3.08 µmol/L, 33.44 ± 16.39 µmol/L, and 12.12 ± 18.10, respectively. With increasing child age, KYN concentration decreased (coefficient: - 0.26; 95%CI: - 0.49, - 0.04; p = 0.021); with increasing lymphocyte count, CIT concentration decreased (coef.: - 0.01; 95% CI: - 0.02,0.001, p = 0.004); the wasted child had decreased KT ratio (coef.: - 0.6; 95% CI: - 1.18, - 0.02; p = 0.042) after adjusting for potential covariates. The CIT concentration was associated with blood neutrophils (coef.: 0.02; 95% CI: 0.01, 0.03; p < 0.001), lymphocytes (coef.: - 0.02; 95% CI: - 0.03, - 0.02; p < 0.001) and monocyte (coef.: 0.06; 95% CI: 0.01, 0.11; p = 0.021); KYN concentration was negatively associated with basophil (coef.: - 0.62; 95% CI: - 1.23, - 0.01; p = 0.048) after adjusting for age. In addition, total stool output (gm) increased (coef.: 793.84; 95% CI: 187.16, 1400.52; p = 0.011) and also increased duration of hospital stay (hour) (coef.: 22.89; 95% CI: 10.24, 35.54; p = 0.001) with increasing CIT concentration. The morphological changes associated with EED may increase the risk of enteric infection and diarrheal disease among children. Further research is critically needed to better understand the complex mechanisms by which EED biomarkers may impact susceptibility to dehydrating diarrhea in children.

Environmental enteric dysfunction and small intestinal histomorphology of stunted children in Bangladesh

There is lack of information on the histological characteristics of the intestinal mucosa in Bangladeshi children. Collection of intestinal biopsy samples and assessment of the histomorphological features is considered to be the traditional gold standard for diagnosis of environmental enteric dysfunction (EED). The purpose of the study was to evaluate the intestinal histological characteristics of stunted children aged between 12-18 months with possible EED. 110 children with chronic malnutrition (52 stunted with length-for-age Z score, LAZ<-2 and 58 at risk of stunting with LAZ <-1 to -2) from the Bangladesh Environmental Enteric Dysfunction (BEED) study protocol who underwent upper gastrointestinal (GI) endoscopy were selected for this study. To explore the association of EED with childhood stunting, upper GI endoscopy was done and the biopsy specimens were studied for histopathology. Villous height and crypt depth were measured and the presence and intensity of inflammatory infiltrates in the lamina propria was investigated. Bivariate analysis was performed to examine the relationship between stunting and histologic morphology. More than 90% children irrespective of nutritional status were diagnosed to have chronic non-specific duodenitis on histopathology. Half of the children from both groups had villous atrophy as well as crypt hyperplasia and lymphocytic infiltration was present in more than 90% children, irrespective of groups. However, no statistically significant difference was observed when compared between the groups. The prevalence of chronic non-specific duodenitis in Bangladeshi children, irrespective of nutritional status, was high. A significant number of these children had abnormal findings in intestinal histomorphology. Trial registration number: ClinicalTrials.gov ID: NCT02812615 Date of first registration: 24/06/2016. https://clinicaltrials.gov/ct2/results?cond=NCT02812615&term=&cntry=&state=&city=&dist.

An Alternative Oat-Containing, Ready-To-Use, Therapeutic Food Does Not Alter Intestinal Permeability or the 16S Ribosomal RNA Fecal Microbiome Configuration Among Children With Severe Malnutrition in Sierra Leone: A Randomized Controlled Trial

BACKGROUND

Previously, a novel oat ready-to-use therapeutic food (o-RUTF) resulted in improved recovery from severe acute malnutrition (SAM) when compared to a standard RUTF (s-RUTF). The o-RUTF contained 18% oat, while the s-RUTF has no cereal ingredients.

OBJECTIVES

We determined the effects of o-RUTF on intestinal permeability, as measured by lactulose permeability, and the 16S ribosomal RNA (rRNA) fecal microbiome configuration of children with SAM.

METHODS

This was a prospective, randomized, double-blinded, controlled clinical trial. Sierra Leonean children aged 6-59 mo with SAM, defined by a midupper arm circumference < 11.5 cm, were randomized to receive o-RUTF or s-RUTF. All children received 7 d of amoxicillin per guidelines. Lactulose permeability testing and fecal 16S rRNA sequencing were performed at baseline and after 4 wk of therapy. The change in lactulose permeability was the primary outcome, while the fecal 16S rRNA configuration at 4 wk was a secondary outcome.

RESULTS

Of the 129 children enrolled, lactulose permeability testing was completed by 100 at baseline and 82 at week 4. After 4 wk of therapeutic feeding, there were no differences in lactulose permeability between the o-RUTF and s-RUTF groups (P = 0.84), and over half of children had increased lactulose permeability (50% s-RUTF compared with 58% o-RUTF, mean difference = -7.5%; 95% CI: -29.2, 15.2; P = 0.50). After 4 wk of feeding, there were no differences in the 16S rRNA configurations between the o-RUTF and s-RUTF groups (Permanova, 999 permutations; P = 0.648; pseudo-F = 0.581), nor were there differences in α or β diversity.

CONCLUSIONS

Despite remarkably different compositions of o-RUTF and s-RUTF, no differences were identified in lactulose permeability or the fecal 16S rRNA configuration among children with SAM receiving these foods. These results suggest that the o-RUTF exerts its beneficial effects through mechanisms other than reducing intestinal permeability or altering the fecal 16S configuration. This trial was registered at clinicaltrials.gov as NCT04334538.

Spatial distribution of stunting and wasting in 6-59 months children in Nepal: analysis using a Bayesian distributional bivariate probit model

The combined burden of stunting and wasting in children under five years is a serious public health concern. The present study aimed to estimate the joint burden of stunting and wasting among children aged 6-59 months and explore its spatial variation across Nepal. The 2016 Nepal Demographic and Health Survey data was used to study acute and chronic childhood malnutrition. A Bayesian distributional bivariate probit geoadditive model was designed to study the linear association and geographical variation of stunting and wasting among 6-59 months, children. Child-related factors such as low birth weight, fever in the last 2 weeks preceding the survey and fourth or greater birth order were associated with a higher likelihood of stunting. The likelihood of a child being stunted was significantly less in the wealthiest households, having improved toilet facilities, and if mothers were overweight. Children from severely food insecure households were significantly more likely, and children from poorer households were significantly less likely to suffer both acute and chronic malnutrition simultaneously. Results from spatial effect showed that children from Lumbini and Karnali had a higher burden of stunting, and the likelihood that achild would have been wasted was significantly higher in Madhesh and Province 1. Immediate nutritional efforts are vital in low-income and severely food insecure households to lessen the risk of stunting and wasting in under children. Disproportionate geographic variations in stunting and wasting warrant sub-regional-specific nutrition intervention to achieve nutrition targets and reduce the burden of childhood malnutrition across the country.

Determining factors of child linear growth from the viewpoint of Bronfenbrenner's Bioecological Theory

OBJECTIVE

To analyze the factors associated with children's linear growth, according to the different subsystems of the 6Cs model and Bronfenbrenner's Bioecological Theory.

DATA SOURCES

Narrative review, carried out in the Scielo, Lilacs, Pubmed, and Science Direct databases, based on research using the terms Bioecological Theory, child growth, and risk factors, combined with the use of Boolean operators.

SUMMARY OF FINDINGS

According to the 6Cs model, proposed based on Bronfenbrenner's Bioecological Theory, the determining factors of children's linear growth are in six interrelated subsystems - cell, child, clan, community, country/state and culture. The empirical studies included in this review made it possible to analyze protection and risk factors within the subsystems. Among the protective factors: are adequate birth weight and satisfactory weight gain, breastfeeding for six months or more; proper hygienic habit of hand washing, proper elimination of feces, and access to clean water. As risk factors: low, birth weight and size, prematurity, multiple deliveries, short interval between deliveries, non-exclusive breastfeeding until the 3rd month, frequency and severity of infectious processes and anemia, little parental education, short maternal statur, inadequate maternal nutritional status, domestic violence, family poverty, food, and nutritional insecurity, living in rural areas or at high altitudes.

CONCLUSION

Children's linear growth is determined by interrelated factors that encompass aspects prior to the child's birth, as well as socioeconomic, political, family and community issues.

Association between Circulating Retinol Binding Protein 4, Body Mass Index, and Biomarkers of Environmental Enteric Dysfunction among Slum-Dwelling Lean Adults in Bangladesh

The relationship of retinol binding protein 4 (RBP4) with biomarkers of intestinal health and gut integrity in adults is unknown. We sought to determine the correlation between plasma RBP4 level and BMI and investigate the relationship of circulating RBP4 concentration with biomarkers of environmental enteric dysfunction among lean adults (body mass index [BMI] < 25.0 kg/m2) in Bangladesh. Overall, 270 adults (135 undernourished with a BMI < 18.5 kg/m2 and 135 healthy controls with a BMI between 18.5 and 24.9 kg/m2) aged 18 to 45 years were evaluated. Multivariable linear regression was performed to test the association between RBP4 and fecal biomarkers of impaired gut health. RBP4 concentration was positively correlated (rho = 0.27, P < 0.001) with BMI and was significantly higher in healthy controls than undernourished adults (P < 0.001), in male than female (P < 0.001), and also in employed (P < 0.001), smokers (P = 0.048) and participants with low Self-Reporting Questionnaire (SRQ)-20 scores (an instrument to screen mental health disorders) (P = 0.049). Statistically significant negative correlations were observed between RBP4 and fecal biomarkers of gut enteropathy including myeloperoxidase (rho = -0.23, P < 0.001), neopterin (rho = -0.30, P < 0.001), and alpha-1 anti-trypsin (rho = -0.21, P < 0.001). Multivariable linear regression analysis showed that increased RBP4 concentration was associated with a significant reduction in fecal neopterin (coefficient = -0.95; 95% confidence interval: -1.44 to -0.45]; P < 0.001) after adjustment for age, sex, nutritional status at enrollment, education, dietary diversity score, SRQ-20 score, improved sanitation, household animal exposure, and alpha-1-acid glycoprotein. The study findings revealed an inverse relationship of plasma RBP4 concentration with fecal biomarkers of altered gut health among slum-dwelling lean adults in Bangladesh.

Stunting among children aged 24-59 months and associations with sanitation, enteric infections, and environmental enteric dysfunction in rural northwest Ethiopia

Stunting is a public health issue of global concern. Despite, poor sanitation, diarrhea, parasitic infections, and environmental enteric dysfunction (EED) are associated with stunting, their link is poorly understood and has not been investigated in Ethiopia. This study was conducted to assess the associations of stunting with sanitation, enteric infections, and EED among children aged 24-59 months in rural northwest Ethiopia. A community-based cross-sectional study was conducted among 224 randomly selected children aged 24-59 months in rural areas of the east Dembiya district. We collected information on household food insecurity and dietary diversity using pre-tested questionnaires adopted from the food and nutrition technical assistance (FANTA) project. We used height-for-age-z score (HAZ) to define stunting. We also used the data collected to measure the environmental exposures of children to intestinal parasitic infections and fecal biomarkers of EED. A multivariable binary logistic regression model was used to assess the association of stunting with sanitation, enteric infections, and EED. Of the 224 children, 33% (95% CI 27, 39%) were stunted. Stunting in children was significantly associated with poor dietary intake (AOR 3.0, 95% CI 1.2, 7.3), open defecation practice (AOR 3.0, 95% CI 1.2, 7.9), presence of animal excreta in the living environment (AOR 3.4, 95% CI 1.2, 9.9), E. coli contamination of drinking water (AOR 4.2, 95% CI 1.1, 15.3), diarrheal disease incidence (AOR 3.4, 95% CI 1.5, 7.7), intestinal parasites in children (AOR 3.3, 95% CI 1.3, 8.8), and higher EED disease activity scores (AOR 2.9, 95% CI 1.2, 6.7). One-third of the children in the study area were stunted and this high prevalence of stunting was associated with poor dietary intake, poor hygiene and sanitation conditions, enteric infections, and EED. Thus, stunting can be prevented by improving sanitation and hygienic conditions to prevent repeated enteric infections in children and by promoting dietary diversity of children.

Nutrition in school-age children: a rationale for revisiting priorities

Middle childhood and early adolescence have received disproportionately low levels of scientific attention relative to other life stages, especially as related to nutrition and health. This is partly due to the justified emphasis on the first 1000 days of life, and the idea that early deficits and consequences may not be fully reversible. In addition, these stages of life may superficially appear less "eventful" than infancy or late adolescence. Finally, there has been historical ambiguity and inconsistency in terminology, depending on whether viewing "childhood" through physiologic, social, legal, or other lenses. Nevertheless, this age bracket, which encompasses most of the primary education and basic schooling years for most individuals, is marked by significant changes, inflection points, and sexually driven divergence in somatic and brain growth and development trajectories. These constitute transformative changes, and thus middle childhood and early adolescence represents a major and last opportunity to influence long-term health and productivity. This review highlights the specificities of growth and development in school age, with a focus on middle childhood and early adolescence (5 years-15 years of age, for the purposes of this review), the role of nutrition, the short- and long-term consequences of inadequate nutrition, and the current global status of nutrition in this age group. Adequate attention and emphasis on nutrition in the school-age years is critical: (a) for maintaining an adequate course of somatic and cognitive development, (b) for taking advantage of this last major opportunity to correct deficits of undernutrition and "catch-up" to normal life course development, and (c) for addressing the nutritional inadequacies and mitigating the longer-term consequences of overnutrition. This review summarizes and provides a rationale for prioritizing nutrition in school-age children, and for the need to revisit priorities and focus on this part of the life cycle to maximize individuals' potential and their contribution to society.

The Immunological Role of Milk Fat Globule Membrane

Human milk is the ideal food for newborns until the age of six months. Human milk can be defined as a dynamic living tissue, containing immunological molecules, such as immunoglobulins, supra-molecular structures, such as the milk fat globule membrane (MFGM), and even entire cells, such as the milk microbiota. The milk composition changes throughout lactation to fulfill the infant’s requirements and reflect the healthy/disease status of the lactating mother. Many bioactive milk components are either soluble or bound to the MFGM. In this work, we focus on the peculiar role of the MFGM components, from their structural organization in fat globules to their route into the gastrointestinal tract. Immunometabolic differences between human and bovine MFGM components are reported and the advantages of supplementing infant formula with the MFGM are highlighted.

Unravelling the reservoirs for colonisation of infants with Campylobacter spp. in rural Ethiopia: protocol for a longitudinal study during a global pandemic and political tensions

INTRODUCTION

Undernutrition is an underlying cause of mortality in children under five (CU5) years of age. Animal-source foods have been shown to decrease malnutrition in CU5. Livestock are important reservoirs for Campylobacter bacteria, which are recognised as risk factors for child malnutrition. Increasing livestock production may be beneficial for improving nutrition of children but these benefits may be negated by increased exposure to Campylobacter and research is needed to evaluate the complex pathways of Campylobacter exposure and infection applicable to low-income and middle-income countries. We aim to identify reservoirs of infection with Campylobacter spp. of infants in rural Eastern Ethiopia and evaluate interactions with child health (environmental enteric dysfunction and stunting) in the context of their sociodemographic environment.

METHODS AND ANALYSIS

This longitudinal study involves 115 infants who are followed from birth to 12 months of age and are selected randomly from 10 kebeles of Haramaya woreda, East Hararghe zone, Oromia region, Ethiopia. Questionnaire-based information is obtained on demographics, livelihoods, wealth, health, nutrition and women empowerment; animal ownership/management and diseases; and water, sanitation and hygiene. Faecal samples are collected from infants, mothers, siblings and livestock, drinking water and soil. These samples are analysed by a range of phenotypic and genotypic microbiological methods to characterise the genetic structure of the Campylobacter population in each of these reservoirs, which will support inference about the main sources of exposure for infants.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Florida Internal Review Board (IRB201903141), the Haramaya University Institutional Health Research Ethics Committee (COHMS/1010/3796/20) and the Ethiopia National Research Ethics Review Committee (SM/14.1/1059/20). Written informed consent is obtained from all participating households. Research findings will be disseminated to stakeholders through conferences and peer-reviewed journals and through the Feed the Future Innovation Lab for Livestock Systems.

Evidence of Concurrent Stunting and Obesity among Children under 2 Years from Socio-Economically Disadvantaged Backgrounds in the Era of the Integrated Nutrition Programme in South Africa

In view of persistent stunting and increasing rates of obesity coexisting among children in the era of the Integrated Nutrition Programme, a cross-sectional study was conducted to determined concurrent stunting and obesity (CSO) and related factors using a random sample of child-mother pairs (n = 400) in Mbombela, South Africa. Sociodemographic data was collected using a validated questionnaire, and stunting (≥2SD) and obesity (>3SD) were assessed through respective length-for-age (LAZ) and body mass index (BAZ) z-scores. Using SPSS 26.0, the mean age of children was 8 (4; 11) months, and poor sociodemographic status was observed, in terms of maternal singlehood (73%), no education or attaining primary education only (21%), being unemployed (79%), living in households with a monthly income below R10,000 (≈$617), and poor sanitation (84%). The z-test for a single proportion showed a significant difference between the prevalence of CSO (41%) and non-CSO (69%). Testing for the two hypotheses using the Chi-square test showed no significant difference of CSO between boys (40%) and girls (41%), while CSO was significantly different and high among children aged 6-11 months (55%), compared to those aged 0-5 months (35%) and ≥12 months (30%). Further analysis using hierarchical logistic regression showed significant associations of CSO with employment (AOR = 0.34; 95%CI: 0.14-0.78), maternal education status (AOR = 0.39; 95%CI: 0.14-1.09) and water access (AOR = 2.47; 95%CI: 1.32; 4.63). Evidence-based and multilevel intervention programs aiming to prevent CSO and addressing stunting, while improving weight status in children with social disadvantages, are necessary.

A Scoping Review: Urinary Markers of Metabolic Maturation in Preterm Infants and Future Interventions to Improve Growth

Background: Growth failure in infants born preterm is a significant issue, increasing the risk of poorer neurodevelopmental outcomes and metabolic syndrome later in life. During the first 1000 days of life biological systems mature rapidly involving developmental programming, cellular senescence, and metabolic maturation, regulating normal growth and development. However, little is known about metabolic maturation in infants born preterm and the relationship with growth. Objective: To examine the available evidence on urinary markers of metabolic maturation and their relationship with growth in infants born preterm. Eligibility criteria: Studies including in this scoping review using qualitative or quantitative methods to describe urinary markers of metabolic maturation and the relationship with growth in infants born preterm. Results: After a screening process 15 titles were included in this review, from 1998-2021 drawing from China (n = 1), Italy (n = 3), Germany (n = 3), Greece (n = 1), Japan (n = 2), Norway (n = 1), Portugal (n = 1), Spain (n = 2) and USA (n = 1). The included studies examined urinary metabolites in 1131 infants. A content analysis identified 4 overarching themes relating to; (i) metabolic maturation relative to gestational age, (ii) metabolic signature and changes in urinary metabolites over time, (iii) nutrition and (iv) growth. Conclusion: The results of this scoping review suggest there are considerable gaps in our knowledge relating to factors associated with metabolic instability, what constitutes normal maturation of preterm infants, and how the development of reference phenome age z scores for metabolites of interest could improve nutritional and growth outcomes.

Diarrhoea, malnutrition, and dehydration associated with school water, sanitation, and hygiene in Metro Manila, Philippines: A cross-sectional study

INTRODUCTION

Diarrhoea, malnutrition, and dehydration threaten the lives of millions of children globally due to inadequate water, sanitation, and hygiene (WaSH). Our study aimed to identify environmental and behavioural risk factors of these health outcomes among schoolchildren in Metro Manila, Philippines.

MATERIALS AND METHODS

We analysed data from a multistage cluster sample of schoolchildren in grades 5, 6, 7, 9, and 10 (ages ~10-15 years old) to investigate WaSH facilities and hygiene practices. Outcomes were: self-reported diarrhoea, measured via questionnaire; observed malnutrition (stunting, undernutrition [underweight/thin and wasted/severely thin], over-nutrition [overweight and obese]), measured via anthropometry; dehydration, measured via urine specific gravity/urine test strips. We used multiple logistic regression to explore correlates.

RESULTS

We included 1558 students from 15 schools in three cities. Over 28% (421) of students had diarrhoea and 68% (956) were dehydrated. Over 15% (227) of students were stunted, ~9% (127) were undernourished, and >21% (321) were over-nourished. Diarrhoea was associated with poor handwashing, while dehydration was associated with the lack of water in school restrooms. Stunting was linked with not using the school restroom, the lack of water in school restrooms, and the lack of hygiene lessons in school. Undernutrition was associated with the lack of a school restroom cleaning policy. Risks of diarrhoea, stunting, and undernutrition decreased as the number of school restrooms increased. Risks of stunting and overnutrition decreased as the numbers of school toilets increased. Having more than seven handwashing basins was associated with decreased risk of dehydration.

DISCUSSION

Findings from our cross-sectional study cannot describe causation. We have found associations that suggest that school restroom cleaning policies, adequate water supply, improved handwashing, and hygiene education are needed to prevent disease. School-based WaSH interventions are recommended to provide water in school WaSH facilities, promote handwashing, and improve hygiene-related knowledge.

A double-blind clinical trial to compare the efficacy and safety of a multiple amino acid-based ORS with the standard WHO-ORS in the management of non-cholera acute watery diarrhea in infants and young children: "VS002A" trial protocol

BACKGROUND

Diarrhea is the second deadliest disease for under-five children globally and the situation is more serious in developing countries. Oral rehydration solution (ORS) is being used as a standard treatment for acute watery diarrhea for a long time. Our objective is to compare the efficacy of amino acid-based ORS "VS002A" compared to standard glucose-based WHO-ORS in infants and young children suffering from acute non-cholera watery diarrhea.

METHODS

It is a randomized, double-blind, two-cell clinical trial at Dhaka Hospital of icddr,b. A total of 312 male children aged 6-36 months old with acute non-bloody watery diarrhea are included in this study. Intervention arm participants get amino acid-based ORS (VS002A) and the control arm gets standard glucose-based WHO-ORS. The primary efficacy endpoint is the duration of diarrhea in the hospital.

DISCUSSION

Oral rehydration therapy (ORT) with the present ORS formulation has certain limitations - it does not reduce the volume, frequency, or duration of diarrhea. Additionally, the failure of present standard ORS to significantly reduce stool output likely contributes to the relatively limited use of ORS by mothers as they do not feel that ORS is helping their child recover from the episode of diarrhea. Certain neutral amino acids (e.g., glycine, L-alanine, L-glutamine) can enhance the absorption of sodium ions and water from the gut. By using this concept, a shelf-stable, sugar-free amino acid-based hydration medicinal food named 'VS002A' that effectively rehydrates, and improves the barrier function of the bowel following infections targeting the gastrointestinal tract has been developed. If the trial shows significant benefits of VS002A use, this may provide evidence to support consideration of the use of VS002A in the present WHO diarrhea management guidelines. Conversely, if there is no evidence of benefit, these results will reaffirm the current guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04677296 . Registered on December 21, 2020.

Key Food Hygiene Behaviors to Reduce Microbial Contamination of Complementary Foods in Rural Bangladesh

Microbial contamination of complementary foods puts young children at risk of developing intestinal infections and could be reduced by improved handwashing and food hygiene practices. We aimed to identify which promoted food hygiene practices are associated with reduced complementary food contamination in a rural population in Bangladesh. We collected cross-sectional data on reported and observed maternal food hygiene behaviors and measured Escherichia coli counts as an indicator of microbial contamination in complementary food samples from 342 children of women enrolled in the Food and Agricultural Approaches to Reducing Malnutrition trial in Sylhet, Bangladesh. We used multivariable logistic regression to examine associations of food hygiene behaviors with food contamination. Approximately 46% of complementary food samples had detectable levels of E. coli. Handwashing with soap at critical times and fresh preparation of food before feeding were strongly associated with reduced odds of food sample contamination (odds ratio [OR]: 0.8, 95% confidence interval [CI]: 0.6-0.9 and OR: 0.3, 95% CI: 0.1-0.7, respectively); in contrast, there was no or only weak evidence that reheating of stored food, safe food storage, and cleanliness of feeding utensils reduced contamination. Reduction in food contamination could be more than halved only when several food hygiene behaviors were practiced in combination. In conclusion, single food hygiene practices showed limited potential and a combined practice of multiple food hygiene behaviors may be needed to achieve a substantial reduction of complementary food contamination.

Child stunting starts in utero: Growth trajectories and determinants in Ugandan infants

Childhood stunting remains a public health burden worldwide. Although many studies have examined early life and in-utero risk factors; most have been observational and have used analytic techniques that make inferences limited to population means, thereby obscuring important within-group variations. This study addressed that important gap. Using data from a birth cohort of Ugandan infants (n = 4528), we applied group-based trajectory modelling to assess diverse patterns of growth among children from birth to 1-year old. A multinomial regression model was conducted to understand the relationship between risk factors and observed patterns across groups. We found that the onset of stunting occurred before birth and followed four distinct growth patterns: chronically stunted (Group 1), recovery (Group 2), borderline stunted (Group 3) and normal (Group 4). The average length-for-age z-score (LAZ) at birth was -2.6, -3.9, -0.6 and 0.5 for Groups 1-4, respectively. Although both Groups 1 and 2 were stunted at birth, stunting persisted in Group 1 while children in Group 2 recovered by the fourth month. Group 3 exhibited mild stunting while Group 4 was normal. Wasting and underweight were observed in all groups, with the highest prevalence of underweight in Group 1. Wasting gradually increased among children born already stunted (Groups 1 and 2). This showed the importance of distinguishing children by their growth patterns rather than aggregating them and only comparing population averages against global growth standards. The design of nutrition interventions should consider the differential factors and potential for growth gains relative to different risks within each group.

Unusual Gram-negative bacteria cause more severe bacterial meningitis than the three classical agents in children

Aim

To compare the characteristics, mortality and sequelae at hospital discharge of childhood bacterial meningitis (BM) caused by the three “classical” agents Neisseria meningitidis, Haemophilus influenzae or Streptococcus pneumoniae versus BM due to other aetiology in Finland, Latin America and Angola.

Methods

This observational study is a secondary analysis of data from five prospective treatment trials on non‐neonatal BM in Finland, Latin America and Angola in 1984–2017.

Results

Of the 1568 cases, 1459 (93%) were caused by the classics, 80 (5%) by other Gram‐negative and 29 (2%) by other Gram‐positive bacteria. Nonclassical Gram‐negative disease was encountered especially in Angola (p < 0.0001). Overall, children in the nonclassical group presented later for treatment and were more often underweight and anaemic (p < 0.001). In multivariate analysis, even if the area was strongest predictor of poor outcome, nonclassical Gram‐negative BM increased the odds for death twofold and the odds for death or severe sequelae 2.5‐fold.

Conclusion

BM of a nonclassical aetiology is a particularly severe disease affecting especially Angolan children poorly armoured to fight infections. Since vaccinations are diminishing the role of classical agents, that of nonclassical agents is growing.

Tryptophan oxidation in young children with environmental enteric dysfunction classified by the lactulose rhamnose ratio

BACKGROUND

In young children, associations between linear growth faltering, environmental enteric dysfunction (EED), and the plasma kynurenine (Kyn)/tryptophan (Trp) ratio (KTR) have led to the proposal that higher Trp catabolism in response to intestinal/systemic inflammation limits Trp availability for protein synthesis, resulting in impaired growth.

OBJECTIVES

We sought to estimate the Trp oxidation rate and the Trp conversion rate to Kyn in young children with and without EED.

METHODS

Children aged 18-24 mo, from urban slums, were assigned to EED (n = 19) or no-EED (n = 26) groups on the basis of a urinary lactulose/rhamnose ratio (LRR) cutoff based on mean + 2 SDs of LRR (≥0.068) in normal age- and sex-matched, high-socioeconomic status children. Plasma KTR and fecal biomarkers of EED were measured. Trp oxidation in the fed state was measured using 13C1-Trp in an oral plateau feeding protocol.

RESULTS

The median (quartile 1, quartile 3) fasted KTR was 0.089 (0.066, 0.110) in children with EED compared with 0.070 (0.050, 0.093) in children with no EED (P = 0.077). However, there was no difference in fed-state Trp oxidation [median (quartile 1, quartile 3) 3.1 (1.3, 5.8) compared with 3.9 (1.8, 6.0) µmol/kg FFM/h, respectively, P = 0.617] or Trp availability for protein synthesis [42.6 (36.5, 45.7) compared with 42.5 (37.9, 46.9) µmol/kg FFM/h, respectively, P = 0.868] between the groups. In contrast, the median (quartile 1, quartile 3) fractional synthesis rates of Kyn [12.5 (5.4, 20.0) compared with 21.3 (16.1, 24.7) %pool/h, P = 0.005] and the fraction of Ala derived from Trp [0.007 (0.005, 0.015) compared with 0.012 (0.008, 0.018), P = 0.037], respectively, in the plasma compartment were significantly slower in the EED group. Fecal biomarkers of EED did not differ between the groups.

CONCLUSIONS

The static plasma KTR value is not a good indicator of the dynamic Trp flux down its oxidative pathway. In a poor sanitary environment, children without EED actually have a faster Kyn synthesis rate, which might be beneficial, because of the cytoprotective and anti-inflammatory functions of downstream metabolites. This study was registered in the Clinical Trials Registry of India as CTRI/2017/02/007921.

Intestinal Inflammation is Significantly Associated With Length Faltering in Preterm Infants at Neonatal Intensive Care Unit Discharge

OBJECTIVE

The aim of the study was to assess intestinal inflammatory measures, urinary intestinal fatty acid-binding protein (IFABP), and fecal calprotectin (FC) by gestational age (GA) and postmenstrual age (PMA) and determine the association between intestinal inflammation and growth in preterm infants from birth to hospital discharge. We hypothesized that intestinal inflammation is associated with adverse growth in preterm infants.

METHODS

We assayed repeated measures of IFABP and FC in 72 hospitalized preterm infants (<34 weeks' gestation). We calculated weight and length z scores at birth and discharge using the Fenton growth reference. Associations between mean IFABP or FC, growth z scores at discharge, and growth faltering (weight or length z score difference <-0.8 from birth to discharge) were assessed using mixed linear and logistic regression models, adjusted for intrafamilial correlation and potential confounders: GA, sex, birth z score, race/ethnicity, and maternal age.

RESULTS

Mean IFABP was greater among infants born at earlier GA and decreased with increasing PMA. Mean FC did not vary by GA or PMA. Higher mean IFABP and FC were associated with lower discharge growth z scores and greater likelihood of growth faltering significant only for mean IFABP and discharge length z score (β = -0.353, 95% confidence interval [CI]: -0.704 to -0.002) and mean IFABP and length faltering (odds ratio [OR] 1.99, P = 0.018).

CONCLUSIONS

Intestinal inflammation, measured by IFABP, was associated with lower length z scores and length faltering at discharge. Interventions to prevent intestinal inflammation may improve linear growth among preterm infants.