Current issues and priorities in childhood nutrition, growth, and infections

A deep learning approach for classifying and predicting children's nutritional status in Ethiopia using LSTM-FC neural networks

BACKGROUND

This study employs a LSTM-FC neural networks to address the critical public health issue of child undernutrition in Ethiopia. By employing this method, the study aims classify children's nutritional status and predict transitions between different undernutrition states over time. This analysis is based on longitudinal data extracted from the Young Lives cohort study, which tracked 1,997 Ethiopian children across five survey rounds conducted from 2002 to 2016. This paper applies rigorous data preprocessing, including handling missing values, normalization, and balancing, to ensure optimal model performance. Feature selection was performed using SHapley Additive exPlanations to identify key factors influencing nutritional status predictions. Hyperparameter tuning was thoroughly applied during model training to optimize performance. Furthermore, this paper compares the performance of LSTM-FC with existing baseline models to demonstrate its superiority. We used Python's TensorFlow and Keras libraries on a GPU-equipped system for model training.

RESULTS

LSTM-FC demonstrated superior predictive accuracy and long-term forecasting compared to baseline models for assessing child nutritional status. The classification and prediction performance of the model showed high accuracy rates above 93%, with perfect predictions for Normal (N) and Stunted & Wasted (SW) categories, minimal errors in most other nutritional statuses, and slight over- or underestimations in a few instances. The LSTM-FC model demonstrates strong generalization performance across multiple folds, with high recall and consistent F1-scores, indicating its robustness in predicting nutritional status. We analyzed the prevalence of children's nutritional status during their transition from late adolescence to early adulthood. The results show a notable decline in normal nutritional status among males, decreasing from 58.3% at age 5 to 33.5% by age 25. At the same time, the risk of severe undernutrition, including conditions of being underweight, stunted, and wasted (USW), increased from 1.3% to 9.4%.

CONCLUSIONS

The LSTM-FC model outperforms baseline methods in classifying and predicting Ethiopian children's nutritional statuses. The findings reveal a critical rise in undernutrition, emphasizing the need for urgent public health interventions.

Ramadan during pregnancy and offspring health outcomes over the life course: a systematic review and meta-analysis

BACKGROUND

Intermittent fasting, such as during Ramadan, is prevalent among pregnant women. However, the association between Ramadan during pregnancy and offspring health along the life course has not been fully established.

OBJECTIVE AND RATIONALE

Fetal programming research indicates that prenatal exposures, particularly during early pregnancy, can cause long-term structural and physiological changes that adversely affect offspring health. Our objective was to systematically identify and assess the evidence regarding Ramadan during pregnancy.

SEARCH METHODS

A total of 31 studies were sourced from PubMed, EMBASE, Web of Science, and EconLit. Included studies evaluated outcomes in individuals with prenatal Ramadan exposure, compared to unexposed Muslim controls. Main outcomes were birth weight, gestational length, and sex ratio in newborns; height, mortality, and cognition in children; and disabilities, chronic diseases, and human capital accumulation in adults. Each study was evaluated for risk of bias. The overall quality of evidence was appraised using the GRADE system. Random-effects meta-analyses were conducted for outcomes analyzed in at least three primary studies.

OUTCOMES

The initial search identified 2933 articles, 1208 duplicates were deleted. There were 31 publications fulfilled the eligibility criteria for the qualitative synthesis; 22 studies were included in meta-analyses. The overall quality of the evidence was low to moderate and differed by study design and outcome. Among newborns, prenatal Ramadan exposure was not associated with birth weight (mean difference (MD) -3 g (95% CI -18 to 11; I2 = 70%) or the likelihood of prematurity (percentage point difference (PPD) 0.19 (95% CI -0.11 to 0.49; I2 = 0%)). The probability that the newborn is male was reduced (PPD -0.14 (95% CI -0.28 to -0.00; I2 = 0%)). This potentially reflects sex-specific mortality rates resulting from adverse in utero circumstances. In childhood, the exposed performed slightly poorer on cognitive tests (MD -3.10% of a standard deviation (95% CI -4.61 to -1.58; I2 = 51%)). Height among the exposed was reduced, and this pattern was already visible at ages below 5 years (height-for-age z-score MD -0.03 (95% CI -0.06 to -0.00; I2 = 76%)). A qualitative literature synthesis revealed that childhood mortality rates were increased in low-income contexts. In adulthood, the prenatally exposed had an increased likelihood of hearing disabilities (odds ratio 1.26 (95% CI 1.09 to 1.45; I2 = 32%)), while sight was not affected. Other impaired outcomes included chronic diseases or their symptoms, and indicators of human capital accumulation such as home ownership (qualitative literature synthesis). The first trimester emerged as a sensitive period for long-term impacts.

WIDER IMPLICATIONS

Despite the need for more high-quality studies to improve the certainty of the evidence, the synthesis of existing research demonstrates that Ramadan during pregnancy is associated with adverse offspring health effects in childhood and especially adulthood, despite an absence of observable effects at birth. Not all health effects may apply to all Muslim communities, which are diverse in backgrounds and behaviors. Notably, moderating factors like daytime activity levels and dietary habits outside fasting hours have hardly been considered. It is imperative for future research to address these aspects.

REGISTRATION NUMBER

PROSPERO (CRD42022325770).

Zinc deficiency enhances sensitivity to influenza A associated bacterial pneumonia in mice

Although zinc deficiency (secondary to malnutrition) has long been considered an important contributor to morbidity and mortality of infectious disease (e.g. diarrhea disorders), epidemiologic data (including randomized controlled trials with supplemental zinc) for such a role in lower respiratory tract infection are somewhat ambiguous. In the current study, we provide the first preclinical evidence demonstrating that although diet-induced acute zinc deficiency (Zn-D: ~50% decrease) did not worsen infection induced by either influenza A (H1N1) or methicillin-resistant staph aureus (MRSA), Zn-D mice were sensitive to the injurious effects of superinfection of H1N1 with MRSA. Although the mechanism underlying the sensitivity of ZnD mice to combined H1N1/MRSA infection is unclear, it was noteworthy that this combination exacerbated lung injury as shown by lung epithelial injury markers (increased BAL protein) and decreased genes related to epithelial integrity in Zn-D mice (surfactant protein C and secretoglobins family 1A member 1). As bacterial pneumonia accounts for 25%-50% of morbidity and mortality from influenza A infection, zinc deficiency may be an important pathology component of respiratory tract infections.

Burden of lower respiratory infections and associated risk factors across regions in Ethiopia: a subnational analysis of the Global Burden of Diseases 2019 study

OBJECTIVE

This analysis is to present the burden and trends of morbidity and mortality due to lower respiratory infections (LRIs), their contributing risk factors, and the disparity across administrative regions and cities from 1990 to 2019.

DESIGN

This analysis used Global Burden of Disease 2019 framework to estimate morbidity and mortality outcomes of LRI and its contributing risk factors. The Global Burden of Disease study uses all available data sources and Cause of Death Ensemble model to estimate deaths from LRI and a meta-regression disease modelling technique to estimate LRI non-fatal outcomes with 95% uncertainty intervals (UI).

STUDY SETTING

The study includes nine region states and two chartered cities of Ethiopia.

OUTCOME MEASURES

We calculated incidence, death and years of life lost (YLLs) due to LRIs and contributing risk factors using all accessible data sources. We calculated 95% UIs for the point estimates.

RESULTS

In 2019, LRIs incidence, death and YLLs among all age groups were 8313.7 (95% UI 7757.6-8918), 59.4 (95% UI 49.8-71.4) and 2404.5 (95% UI 2059.4-2833.3) per 100 000 people, respectively. From 1990, the corresponding decline rates were 39%, 61% and 76%, respectively. Children under the age of 5 years account for 20% of episodes, 42% of mortalities and 70% of the YLL of the total burden of LRIs in 2019. The mortality rate was significantly higher in predominantly pastoralist regions-Benishangul-Gumuz 101.8 (95% UI 84.0-121.7) and Afar 103.7 (95% UI 86.6-122.6). The Somali region showed the least decline in mortality rates. More than three-fourths of under-5 child deaths due to LRIs were attributed to malnutrition. Household air pollution from solid fuel attributed to nearly half of the risk factors for all age mortalities due to LRIs in the country.

CONCLUSION

In Ethiopia, LRIs have reduced significantly across the regions over the years (except in elders), however, are still the third-leading cause of mortality, disproportionately affecting children younger than 5 years old and predominantly pastoralist regions. Interventions need to consider leading risk factors, targeted age groups and pastoralist and cross-border communities.

Integrated Proteomics and Metabolomics Analysis to Explore the Amelioration Mechanisms of Rosa roxburghii Tratt Fruit Polyphenols on Lipopolysaccharide-Induced Acute Lung Injury Mice

Acute lung injury (ALI) is the main cause of death for the elderly and children due to its high morbidity and mortality rates. Plant-derived functional foods are becoming increasingly important to the healthcare and food industries for adjunctive and alternative treatments of ALI. Polyphenols have been regarded to be beneficial to the prevention and amelioration of ALI. Rosa roxburghii Tratt fruit polyphenols (RRTP) has potential to prevent ALI, but mechanism remains unclear. This study was set up to systematically analyze the RRTP extract active ingredients, comprehensively evaluate its protective effects via lung histopathological examination, protein concentration, and cytokines production in ALI mice induced by lipopolysaccharide (LPS), and finally revealed alleviation mechanisms of the regulatory effects of RRTP by proteomics and metabolomics approach. The results demonstrated RRTP could synergistically exert significant preventive effects against ALI by notably ameliorating lung histopathological damage and pulmonary capillary permeability in ALI mice, inhibiting lung tissue inflammatory response and acute phase proteins and S-100 calcium binding proteins, suppressing excessive activation of complement and coagulation cascades, and regulating disordered lipids metabolism and amino acid metabolism. This study illustrated that RRTP has obvious advantages in ALI adjunctive therapy and revealed the complicated amelioration mechanisms, which provides a breakthrough for the development and demonstration of RRTP as a nutritional compound additive for complementary therapy of ALI.

Essential childhood immunization in 43 low- and middle-income countries: Analysis of spatial trends and socioeconomic inequalities in vaccine coverage

BACKGROUND

Globally, access to life-saving vaccines has improved considerably in the past 5 decades. However, progress has started to slow down and even reverse in recent years. Understanding subnational heterogeneities in essential child immunization will be critical for closing the global vaccination gap.

METHODS AND FINDINGS

We use vaccination information for over 220,000 children across 1,366 administrative regions in 43 low- and middle-income countries (LMICs) from the most recent Demographic and Health Surveys. We estimate essential immunization coverage at the national and subnational levels and quantify socioeconomic inequalities in such coverage using adjusted concentration indices. Within- and between-country variations are summarized via the Theil index. We use local indicator of spatial association (LISA) statistics to identify clusters of administrative regions with high or low values. Finally, we estimate the number of missed vaccinations among children aged 15 to 35 months across all 43 countries and the types of vaccines most often missed. We show that national-level vaccination rates can conceal wide subnational heterogeneities. Large gaps in child immunization are found across West and Central Africa and in South Asia, particularly in regions of Angola, Chad, Nigeria, Guinea, and Afghanistan, where less than 10% of children are fully immunized. Furthermore, children living in these countries consistently lack all 4 basic vaccines included in the WHO's recommended schedule for young children. Across most countries, children from poorer households are less likely to be fully immunized. The main limitations include subnational estimates based on large administrative divisions for some countries and different periods of survey data collection.

CONCLUSIONS

The identified heterogeneities in essential childhood immunization, especially given that some regions consistently are underserved for all basic vaccines, can be used to inform the design and implementation of localized intervention programs aimed at eliminating child suffering and deaths from existing and novel vaccine-preventable diseases.

Analysis of protective effects of Rosa Roxburghii Tratt fruit polyphenols on lipopolysaccharide-induced acute lung injury through network pharmacology and metabolomics

Acute lung injury (ALI) is a respiratory disease with high morbidity and mortality rates and is the primary cause of death in children and the elderly around the world. The use of Chinese foods in the complementary and alternative treatment of ALI has attracted more and more attention. This study aimed to explore the anti-ALI activity of Chinese functional foods Rosa roxburghii Tratt fruit polyphenols (RRTP). RRTP was administered to lipopolysaccharide-induced ALI mice, and its protective effects were comprehensively evaluated by lung histopathological examination, wet/dry (W/D) ratio, and cytokine production. Metabolomics analysis was used to identify the differential metabolites and metabolic pathways in plasma, and molecular docking and systemic biology-based network pharmacology assay were performed to explore the active components and potential therapeutic targets. The results indicated that RRTP significantly attenuated the severity of pathological changes and pulmonary capillary permeability. Furthermore, RRTP limited the increase in tumor necrosis factor alpha (TNF-α), interleukin 1β (IL-1β), and interleukin 6 (IL-6) levels and the decrease in interleukin 10 (IL-10) levels in ALI mice. Metabolomics studies revealed that RRTP markedly affected 19 different metabolites, three amino acid metabolism pathways, and sphingolipid metabolism. Moreover, network pharmacology identified AKT1 (AKT serine/threonine kinase 1), TP53, IL-6, VEGFA (vascular endothelial growth factor A), and TNF (tumor necrosis factor) as the most promising target proteins, while quercetin, luteolin, and kaempferol were the core active components of RRTP. This study investigated the complex mechanisms of RRTP against ALI for the first time, and provided a foundation for the application of RRTP as a functional food, facilitating the research of nutritional food additives for the adjuvant treatment of ALI.

Optimising the management of childhood acute diarrhoeal disease using a rapid test-and- treat strategy and/or Lactobacillus reuteri DSM 17938: a multicentre, randomised, controlled, factorial trial in Botswana

INTRODUCTION

The study aim was to determine if rapid enteric diagnostics followed by the provision of targeted antibiotic therapy ('test-and-treat') and/or Lactobacillus reuteri DSM 17938 would improve outcomes in children hospitalised in Botswana with acute gastroenteritis.

METHODS

This was a multicentre, randomised, factorial, controlled, trial. Children aged 2-60 months admitted for acute non-bloody diarrhoea to four hospitals in southern Botswana were eligible. Participants were assigned to treatment groups by web-based block randomisation. Test-and-treat results were not blinded, but participants and research staff were blinded to L. reuteri/placebo assignment; this was dosed as 1×10⁸ cfu/mL by mouth daily and continued for 60 days. The primary outcome was 60-day age-standardised height (HAZ) adjusted for baseline HAZ. All analyses were by intention to treat. The trial was registered at Clinicaltrials.gov.

RESULTS

Recruitment began on 12 June 2016 and continued until 24 October 2018. There were 66 participants randomised to the test-and-treat plus L. reuteri group, 68 randomised to the test-and-treat plus placebo group, 69 to the standard care plus L. reuteri group and 69 to the standard care plus placebo group. There was no demonstrable impact of the test-and-treat intervention (mean increase of 0.01 SD, 95% CI -0.14 to 0.16 SD) or the L. reuteri intervention (mean decrease of 0.07 SD, 95% CI -0.22 to 0.08 SD) on adjusted HAZ at 60 days.

CONCLUSIONS

In children hospitalised for acute gastroenteritis in Botswana, neither a test-and-treat algorithm targeting enteropathogens, nor a 60-day course of L. reuteri DSM 17938, were found to markedly impact linear growth or other important outcomes. We cannot exclude the possibility that test-and-treat will improve the care of children with significant enteropathogens (such as Shigella) in their stool.

TRIAL REGISTRATION NUMBER

NCT02803827.

Genomics and breeding innovations for enhancing genetic gain for climate resilience and nutrition traits

KEY MESSAGE

Integrating genomics technologies and breeding methods to tweak core parameters of the breeder's equation could accelerate delivery of climate-resilient and nutrient rich crops for future food security. Accelerating genetic gain in crop improvement programs with respect to climate resilience and nutrition traits, and the realization of the improved gain in farmers' fields require integration of several approaches. This article focuses on innovative approaches to address core components of the breeder's equation. A prerequisite to enhancing genetic variance (σ2g) is the identification or creation of favorable alleles/haplotypes and their deployment for improving key traits. Novel alleles for new and existing target traits need to be accessed and added to the breeding population while maintaining genetic diversity. Selection intensity (i) in the breeding program can be improved by testing a larger population size, enabled by the statistical designs with minimal replications and high-throughput phenotyping. Selection priorities and criteria to select appropriate portion of the population too assume an important role. The most important component of breeder's equation is heritability (h2). Heritability estimates depend on several factors including the size and the type of population and the statistical methods. The present article starts with a brief discussion on the potential ways to enhance σ2g in the population. We highlight statistical methods and experimental designs that could improve trait heritability estimation. We also offer a perspective on reducing the breeding cycle time (t), which could be achieved through the selection of appropriate parents, optimizing the breeding scheme, rapid fixation of target alleles, and combining speed breeding with breeding programs to optimize trials for release. Finally, we summarize knowledge from multiple disciplines for enhancing genetic gains for climate resilience and nutritional traits.

Effectiveness of interventions to manage acute malnutrition in children under 5 years of age in low- and middle-income countries: A systematic review

Background

Childhood malnutrition is a major public health concern as it is associated with significant short- and long-term morbidity and mortality.

Objectives

To comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization protocol using facility- and community-based approaches as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use and vitamin A supplementation.

Search methods

We searched relevant electronic databases till 11 February 2019. No date or language restrictions were applied.

Selection criteria

We included randomised controlled trials (RCTs) and quasi-experimental studies including controlled before-after (CBA) studies and interrupted time series (ITS) studies.

Data collection and analysis

Two review authors independently screened studies for relevance, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software and set out the main findings of the review in "Summary of findings" tables.

Main results

This review summarises findings from a total of 42 studies (48 papers) including 35,017 children. Thirty-three of the included studies were RCTs; six studies were quasi-experimental and three studies were cost studies. Majority of the studies were judged to be at high risk of bias for blinding of the participants, personnel and outcome assessment. Majority of the outcomes were rated as either moderate or low quality. Outcomes were downgraded mainly due to study limitations, high heterogeneity, imprecision and small sample size. Community-based strategies to screen and manage SAM/MAM versus no community-based strategies (two studies): Integrated community-based management probably improves recovery rate by 4% [risk ratio (RR): 1.04; 95% confidence interval (CI): 1.00 to 1.09; one study; 1,957 participants; moderate-quality outcome], and reduces weight gain by 0.8 g·kg^-1·day^-1 [mean difference (MD): -0.80 g·kg^-1·day^-1; 95% CI: -0.82 to -0.78; one study; 1,957 participants; moderate-quality outcome] compared with no community-based strategies, while mortality was similar between the two groups (RR: 0.93; 95% CI: 0.60 to 1.45; one study; 1,957 participants; moderate-quality outcome). Facility-based strategies to screen and manage uncomplicated SAM versus other standard of care (four studies): There was no evidence of effect on recovery (RR: 1.00; 95% CI: 0.80, 1.25; one study; 60 participants; very-low-quality evidence) and mortality (RR: 1.21; 95% CI: 0.75 to 1.94; two studies; 473 participants; low-quality outcome). Facility-based management with RUTF versus F100 ("catch-up" formula to rebuild wasted tissues containing 100 kcal and 2.9 g protein per 100 ml) for SAM (three studies): There was no evidence of effect on weight gain (MD: 2 g·kg^-1·day^-1; 95% CI: -0.23 to 4.23; three studies; 266 participants; very-low-quality outcome) and mortality (RR: 1.20; 95% CI: 0.34 to 4.22; two studies; 168 participants; low-quality outcome). Community-based management of SAM with standard RUTF compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUTF was compared to non-milk/peanut butter-based RUTF (RR: 1.03; 95% CI: 0.99 to 1.08; five studies; 5743 participants; I² 50%; moderate quality outcome), energy-dense, home-prepared food (RR: 1.14; 95% CI 0.95 to 1.36; four studies; 959 participants; I² 75%; low quality outcome), or high oleic RUTF (RR: 1.06; 95% CI: 0.85 to 1.31; one study; 141 participants; moderate quality outcome). Standard RUTF may improve weight gain by 0.5 g·kg^-1·day^-1 (MD: 0.5 g·kg^-1·day^-1; 95% CI: 0.02 to 0.99; three studies; 3,069 participants; low-quality outcome) when compared with non-milk/peanut butter-based RUTF and by 5.5 g·kg^-1·day^-1 when compared with F100 (MD: 5.50 g·kg^-1·day^-1; 95% CI: 2.92 to 8.08; one study; 70 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUTF was compared with other foods (RR: 0.99; 95% CI: 0.69 to 1.41; nine studies; 7,667 participants; low-quality outcome). RUSF for MAM compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUSF was compared with local/home made food (RR: 0.92; 95% CI: 0.64 to 1.33; three studies; 435 participants; low-quality outcome) and whey RUSF (RR: 0.96; 95% CI: 0.92 to 1.00; one study; 2230 participants; high-quality outcome); while standard RUSF may improve recovery by 7% when compared with corn-soy blend (CSB) (RR: 1.07; 95% CI: 1.02 to 1.13; six studies; 5,744 participants; low-quality outcome). There was no evidence of effect on weight gain when standard RUSF was compared with local home made food (MD: -0.75 g·kg^-1·day^-1; 95% CI: -2.03 to 0.43; one study; 73 participants; low-quality outcome) and whey RUSF (MD: -0.16 g·kg^-1·day^-1; 95% CI: -0.33 to 0.01; one study; 2,230 participants; high-quality outcome); while standard RUSF may improve weight gain by 0.49 g·kg^-1·day^-1 when compared with CSB (MD: 0.49 g·kg^-1·day^-1; 95% CI: 0.10 to 0.87; five studies; 4,354 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUSF was compared with other foods (RR: 0.98; 95% CI: 0.57 to 1.68; eight studies; 8,310 participants; moderate-quality outcome). Prophylactic antibiotic versus no antibiotic (three studies): Prophylactic antibiotic therapy for uncomplicated SAM improves recovery rate by 6% (RR: 1.06; 95% CI: 1.03 to 1.08; two studies; 5,166 participants; high-quality outcome), probably improves weight gain by 0.67 g·kg^-1·day^-1 (MD: 0.67 g·kg^-1·day^-1; 95% CI: 0.28, 1.06; two studies; 5,052 participants; moderate-quality outcome) and probably reduces mortality by 26% (RR: 0.74; 95% CI: 0.55, 0.98; three studies; 6944 participants; moderate quality outcome) compared to no antibiotics group. High-dose vitamin A versus low-dose vitamin A (two studies): There was no evidence of effect on weight gain (MD: 0.05 g·kg^-1·day^-1; 95% CI: -0.08 to 0.18; one study; 207 participants; moderate-quality outcome) and mortality (RR: 7.07; 95% CI: 0.37 to 135.13; one study; 207 participants; moderate-quality outcome).

Authors’ conclusions

Limited data show some benefit of integrated community-based screening, identification and management of SAM and MAM on improving recovery. Facility-based screening and management of uncomplicated SAM has no benefit on recovery and mortality, while the effect of F100 for SAM is similar to RUTF for weight gain and mortality. Local food and whey RUSF have similar effects as standard RUSF on recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate, weight gain and reduces mortality, while limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.

An untargeted metabolomics approach to investigate the wine-processed mechanism of Scutellariae radix in acute lung injury

ETHNOPHARMACOLOGICAL RELEVANCE

Scutellariae radix (SR) is one of the most popular traditional Chinese medicines (TCM). Crude SR (CSR) and wine-processed SR (WSR) are the two most common commercial specifications. According to the theories of TCM, wine-processing increases the inclination and direction of SR's actions, thereby strengthening its efficacy in clearing the upper-energizer lung damp heat. The pharmacological mechanism-related research on WSR for the treatment of lung disease is limited and needs to be expanded.

AIM OF THE STUDY

The aim of this report was to identify the relevant biological pathways by assessing changes in plasma metabolites between CSR and WSR in a lipopolysaccharide (LPS)-induced acute lung injury (ALI) model, and thus, revealed the potential mechanism of wine processing in SR.

MATERIALS AND METHODS

Rats with LPS-induced ALI were treated with CSR and WSR. The contents of inflammatory cytokines and histopathological examination were determined to explore the effects of CSR and WSR. Next, the metabolic profiling of rat plasma samples was performed by ultra-performance liquid chromatography-quadrupole time-of-flight mass spectrometry (UPLC-QTOF-MS). Then, principal component analysis (PCA) were used to provide an overview for all of the groups and orthogonal partial least squares-discriminant analysis (OPLS-DA) was utilized to maximize the discrimination and present the differences in the metabolite between all of the groups.

RESULTS

WSR exhibited a more remarkable effect on improving ALI than CSR by reducing the levels of inflammatory factors, including nitric oxide (NO), tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), and interleukin-8 (IL-8). On the basis of UPLC-QTOF-MS technology, an unequal curative effect was revealed by nontargeting metabolomics. Sixteen biomarkers were discovered in the plasma of LPS-induced rats. Pathway analysis indicated that CSR acted on ALI by regulating the abnormal sphingolipid metabolism pathways; however, an WSR-mediated cure of ALI was linked primarily to reversing the abnormality of retinol metabolism pathways and tryptophan metabolism pathways.

CONCLUSIONS

This report examined the underlying wine-processing mechanism of SR from the perspective of plasma metabolites. In addition, this work provided a novel and valuable insight into interpretation of the processing mechanisms of TCM in a holistic way.

Water, sanitation and hygiene (WASH) in sub-Saharan Africa and associations with undernutrition, and governance in children under five years of age: a systematic review

Associations between different forms of malnutrition and environmental conditions, including water, sanitation and hygiene (WASH), may contribute towards persistently poor child health, growth and cognitive development. Experiencing poor nutrition in utero or during early childhood is furthermore associated with chronic diseases later in life. The primary responsibility for provision of water and sanitation, as a basic service and human right, lies with the State; however, a number of stakeholders are involved. The situation is most critical in sub-Saharan Africa (SSA), where, in 2015, 311 million people lacked a safe water source, and >70% of SSA populations were living without adequate sanitation. The aim of this paper was to conduct a systematic review to investigate the state of literature concerned with WASH and its association with nutritional status, and governance in children from birth to 5 years of age in SSA. Articles were sourced from PubMed Central, Science Direct and ProQuest Social Science databases published between 1990 and 2017. The PRISMA Statement was utilised and this systematic review is registered with PROSPERO (CRD42017071700). The search terms returned 15,351 articles for screening, with 46 articles included. This is indicative of a limited body of knowledge; however, the number of publications on this topic has been increasing, suggesting burgeoning field of interest. Targeted research on the governance of WASH through the identification of the various role players and stakeholders at various levels, while understanding the policy environment in relation to particular health-related outcomes is imperative to address the burden of child undernutrition.

A qualitative exploration of behavioral factors affecting mothers of malnourished children under 5 years old in Kiribati

Background: In Kiribati, malnutrition is the leading cause of death for children aged less than 5 years. The purpose of this study was to explore contributing behavioral factors among mothers of malnourished children under 5 years old in Kiribati. Methods: This qualitative study was conducted in an urban area of South Tarawa among mothers of malnourished children aged less than 5 years in 11 public health centers in 2016. The study included 9 focus group discussions, with a sub sample of 3 to 4 in each group, having a total of 35 participants. Using a semi-structured questionnaire, data was collected and thematic analysis was applied to analysis the data.  Results: Seven main themes were identified including; knowledge, behaviors, perceived severity, perceived benefits to action, perceived barriers and cultural related issues. These encompassed a variety of reasons which could explain the malnutrition in children of those particular mothers. Conclusion: In order to tackle malnutrition in Kiribati, it is crucial to identify the main factors that are hindering this preventable disease. This study provides information essential to enhanced decision making, health care delivery planning and has policy implications for the improvement of quality of health care in Kiribati.

Comparative effectiveness and safety of interventions for acute diarrhea and gastroenteritis in children: A systematic review and network meta-analysis

BACKGROUND

Many interventions have shown effectiveness in reducing the duration of acute diarrhea and gastroenteritis (ADG) in children. Yet, there is lack of comparative efficacy of interventions that seem to be better than placebo among which, the clinicians must choose. Our aim was to determine the comparative effectiveness and safety of the pharmacological and nutritional interventions for reducing the duration of ADG in children.

METHODS

Data sources included Medline, Embase, CENTRAL, CINAHL, LILACS, and Global-Health up to May 2017. Eligible trials compared zinc (ZN), vitamin A, micronutrients (MN), probiotics, prebiotics, symbiotics, racecadotril, smectite(SM), loperamide, diluted milk, lactose-free formula(LCF), or their combinations, to placebo or standard treatment (STND), or among them. Two reviewers independently performed screening, review, study selection and extraction. The primary outcome was diarrhea duration. Secondary outcomes were stool frequency at day 2, diarrhea at day 3, vomiting and side effects. We performed a random effects Bayesian network meta-analysis to combine the direct and indirect evidence for each outcome. Mean differences and odds ratio with their credible intervals(CrI) were calculated. Coherence and transitivity assumptions were assessed. Meta-regression, subgroups and sensitivity analyses were conducted to explore the impact of effect modifiers. Summary under the cumulative curve (SUCRA) values with their CrI were calculated. We assessed the evidence quality and classified the best interventions using the Grading of Recommendations, Assessment, Development & Evaluation (GRADE) approach for each paired comparison.

RESULTS

A total of 174 studies (32,430 children) proved eligible. Studies were conducted in 42 countries of which most were low-and middle-income countries (LMIC). Interventions were grouped in 27 categories. Most interventions were better than STND. Reduction of diarrhea varied from 12.5 to 51.1 hours. The combinations Saccharomyces boulardii (SB)+ZN, and SM+ZN were considered the best interventions (i.e., GRADE quality of evidence: moderate to high, substantial superiority to STND, reduction in duration of 35 to 40 hours, and large SUCRA values), while symbiotics (combination of probiotics+prebiotics), ZN, loperamide and combinations ZN+MN and ZN+LCF were considered inferior to the best and better than STND [Quality: moderate to high, superior to STND, and reduction of 17 to 25 hours]. In subgroups analyses, effect of ZN was higher in LMIC and was not present in high-income countries (HIC). Vitamin A, MN, prebiotics, kaolin-pectin, and diluted milk were similar to STND [Quality: moderate to high]. The remainder of the interventions had low to very-low evidence quality. Loperamide was the only intervention with more side effects than STND [Quality: moderate].

DISCUSSION/CONCLUSION

Most interventions analyzed (except vitamin A, micronutrients, prebiotics, and kaolin-pectin) showed evidence of superiority to placebo in reducing the diarrhea. With moderate-to high-quality of evidence, SB+ZN and SM+ZN, demonstrated the best combination of evidence quality and magnitude of effect while symbiotics, loperamide and zinc proved being the best single interventions, and loperamide was the most unsafe. Nonetheless, the effect of zinc, SB+ZN and SM+ZN might only be applied to children in LMIC. Results suggest no further role for studies comparing interventions against no treatment or placebo, or studies testing loperamide, MN, kaolin-pectin, vitamin A, prebiotics and diluted milk.

PROSPERO REGISTRATION

CRD42015023778.

Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provides an up-to-date analysis of the burden of diarrhoea in 195 countries. This study assesses cases, deaths, and aetiologies in 1990-2016 and assesses how the burden of diarrhoea has changed in people of all ages.

METHODS

We modelled diarrhoea mortality with a Bayesian hierarchical modelling platform that evaluates a wide range of covariates and model types on the basis of vital registration and verbal autopsy data. We modelled diarrhoea incidence with a compartmental meta-regression tool that enforces an association between incidence and prevalence, and relies on scientific literature, population representative surveys, and health-care data. Diarrhoea deaths and episodes were attributed to 13 pathogens by use of a counterfactual population attributable fraction approach. Diarrhoea risk factors are also based on counterfactual estimates of risk exposure and the association between the risk and diarrhoea. Each modelled estimate accounted for uncertainty.

FINDINGS

In 2016, diarrhoea was the eighth leading cause of death among all ages (1 655 944 deaths, 95% uncertainty interval [UI] 1 244 073-2 366 552) and the fifth leading cause of death among children younger than 5 years (446 000 deaths, 390 894-504 613). Rotavirus was the leading aetiology for diarrhoea mortality among children younger than 5 years (128 515 deaths, 105 138-155 133) and among all ages (228 047 deaths, 183 526-292 737). Childhood wasting (low weight-for-height score), unsafe water, and unsafe sanitation were the leading risk factors for diarrhoea, responsible for 80·4% (95% UI 68·2-85·0), 72·1% (34·0-91·4), and 56·4% (49·3-62·7) of diarrhoea deaths in children younger than 5 years, respectively. Prevention of wasting in 1762 children (95% UI 1521-2170) could avert one death from diarrhoea.

INTERPRETATION

Substantial progress has been made globally in reducing the burden of diarrhoeal diseases, driven by decreases in several primary risk factors. However, this reduction has not been equal across locations, and burden among adults older than 70 years requires attention.

FUNDING

Bill & Melinda Gates Foundation.

Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Lower respiratory infections are a leading cause of morbidity and mortality around the world. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016, provides an up-to-date analysis of the burden of lower respiratory infections in 195 countries. This study assesses cases, deaths, and aetiologies spanning the past 26 years and shows how the burden of lower respiratory infection has changed in people of all ages.

METHODS

We used three separate modelling strategies for lower respiratory infections in GBD 2016: a Bayesian hierarchical ensemble modelling platform (Cause of Death Ensemble model), which uses vital registration, verbal autopsy data, and surveillance system data to predict mortality due to lower respiratory infections; a compartmental meta-regression tool (DisMod-MR), which uses scientific literature, population representative surveys, and health-care data to predict incidence, prevalence, and mortality; and modelling of counterfactual estimates of the population attributable fraction of lower respiratory infection episodes due to Streptococcus pneumoniae, Haemophilus influenzae type b, influenza, and respiratory syncytial virus. We calculated each modelled estimate for each age, sex, year, and location. We modelled the exposure level in a population for a given risk factor using DisMod-MR and a spatio-temporal Gaussian process regression, and assessed the effectiveness of targeted interventions for each risk factor in children younger than 5 years. We also did a decomposition analysis of the change in LRI deaths from 2000-16 using the risk factors associated with LRI in GBD 2016.

FINDINGS

In 2016, lower respiratory infections caused 652 572 deaths (95% uncertainty interval [UI] 586 475-720 612) in children younger than 5 years (under-5s), 1 080 958 deaths (943 749-1 170 638) in adults older than 70 years, and 2 377 697 deaths (2 145 584-2 512 809) in people of all ages, worldwide. Streptococcus pneumoniae was the leading cause of lower respiratory infection morbidity and mortality globally, contributing to more deaths than all other aetiologies combined in 2016 (1 189 937 deaths, 95% UI 690 445-1 770 660). Childhood wasting remains the leading risk factor for lower respiratory infection mortality among children younger than 5 years, responsible for 61·4% of lower respiratory infection deaths in 2016 (95% UI 45·7-69·6). Interventions to improve wasting, household air pollution, ambient particulate matter pollution, and expanded antibiotic use could avert one under-5 death due to lower respiratory infection for every 4000 children treated in the countries with the highest lower respiratory infection burden.

INTERPRETATION

Our findings show substantial progress in the reduction of lower respiratory infection burden, but this progress has not been equal across locations, has been driven by decreases in several primary risk factors, and might require more effort among elderly adults. By highlighting regions and populations with the highest burden, and the risk factors that could have the greatest effect, funders, policy makers, and programme implementers can more effectively reduce lower respiratory infections among the world's most susceptible populations.

FUNDING

Bill & Melinda Gates Foundation.

Follow-up consultations on growth and development: the meaning for quilombo mothers

Abstract Objective: To know the meanings of follow-up consultations on growth and development from the perspective of mothers living in quilombos. Method: A qualitative research was carried out with 26 mothers of under one-year-old children who attended the Family Health Unit of Ilha de Maré, Bahia, Brazil. The data of the interviews were systematized using analysis of thematic content based on symbolic interactionism. Results: Four categories were identified that reflect the symbolism of quilombola mothers about child consultations: growth assessment, examination of the general health conditions, guidance on health education, and the identification of health problems/risk factors and intervention. Conclusion: As quilombola mothers see children's consultations in a way similar to that recommended by the Ministry of Health and the scientific evidence shows their relevance to reduce morbidity and mortality rates, this research may guide educational measures aiming at the adherence of more children to the service.

Poor nutrition from first foods: A cross-sectional study of complementary feeding of infants and young children in six remote Aboriginal communities across northern Australia

AIM

To describe the first foods of Aboriginal and Torres Strait Islander infants and young children who were recruited to a nutrition promotion and anaemia prevention program conducted from 2010 to 2012, in six remote communities across northern Australia.

METHODS

Food records (24-hour diet history, food variety checklist) were completed on recruitment by interview with a parent or carer. Cross-sectional analysis assessed the proportion of participants consuming recommended and not-recommended foods and drinks and meeting recommendations for meal frequency and dietary diversity.

RESULTS

Of 245 Aboriginal and Torres Strait Islander participants aged 6-24 months, 227 (92.7%) had a recruitment food record. On the previous day, most (67.4%) had breastmilk, nearly all (98.2%) ate solid food, but only 13% ate fruit, 33% had neither fruit nor vegetables, and 25% had sweet drinks. Children living in smaller households (3-5 people) were more likely to meet the criteria for frequency of meals than those living in larger households of 12-31 people (93% vs 78%, P = 0.012 for trend over household size). Only 30% met the criteria for dietary diversity. Where information was available (n = 91), dietary diversity was adequate more often in 'pay week' compared to 'not pay week' (31.3% vs 9.3%, P = 0.007).

CONCLUSION

Support for current beneficial breast-feeding practices and promotion of nutrient-dense complementary foods, need to be embedded in initiatives for improved family food security. Good nutrition in early life can reduce the disparity in health, education and economic status between Aboriginal and Torres Strait Islander peoples and other Australians.

Life History theory hypotheses on child growth: Potential implications for short and long-term child growth, development and health

Life history theory integrates ecological, physiological, and molecular layers within an evolutionary framework to understand organisms' strategies to optimize survival and reproduction. Two life history hypotheses and their implications for child growth, development, and health (illustrated in the South African context) are reviewed here. One hypothesis suggests that there is an energy trade-off between linear growth and brain growth. Undernutrition in infancy and childhood may trigger adaptive physiological mechanisms prioritizing the brain at the expense of body growth. Another hypothesis is that the period from conception to infancy is a critical window of developmental plasticity of linear growth, the duration of which may vary between and within populations. The transition from infancy to childhood may mark the end of a critical window of opportunity for improving child growth. Both hypotheses emphasize the developmental plasticity of linear growth and the potential determinants of growth variability (including the role of parent-offspring conflict in maternal resources allocation). Implications of these hypotheses in populations with high burdens of undernutrition and infections are discussed. In South Africa, HIV/AIDS during pregnancy (associated with adverse birth outcomes, short duration of breastfeeding, and social consequences) may lead to a shortened window of developmental plasticity of growth. Furthermore, undernutrition and infectious diseases in children living in South Africa, a country undergoing a rapid nutrition transition, may have adverse consequences on individuals' cognitive abilities and risks of cardio-metabolic diseases. Studies are needed to identify physiological mechanisms underlying energy allocation between biological functions and their potential impacts on health.

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.

Role of Primary Health Care in child hospitalization due to pneumonia: a case-control study

Objective:

to evaluate the association of primary health care and other potential factors in relation to hospitalization due to pneumonia, among children aged under five years.

Method:

epidemiological study with a case-control, hospital-based design, which included 345 cases and 345 controls, matched according to gender, age and hospital. Data were collected using a pre-coded questionnaire and the Primary Care Assessment Tool, analyzed by means of multivariate logistic regression, following the assumptions of a hierarchical approach.

Results:

the protective factors were: family income >US$216.12 (OR=0.68), weight gain during pregnancy ≥10 kg (OR=0.68), quality of Primary Health Care (OR for scores >3.41=0.57; OR for scores >3.17 and ≤3.41=0.50), gastro-esophageal reflux (OR=0.55), overweight (OR=0.37) and birth interval ≥48 months (OR=0.28). The risk factors included: parity (2 childbirths: OR=4.60; ≥3 childbirths: OR=3.25), out-of-date vaccination (OR=2.81), undernutrition (OR=2.53), history of wheezing (≥3 episodes OR=2.37; 1 episode: OR=2.13), attendance at daycare center (OR=1.67), and use of medicines over the past month (OR=1.67).

Conclusion:

primary health care and its child health care practices, such as nutritional monitoring, immunization, care to prevalent illnesses, prenatal care and family planning need to be prioritized to avoid child hospitalization due to pneumonia.

Overweight and obesity epidemic in Ghana-a systematic review and meta-analysis

Background

In many low and middle income countries (LMICs), the distribution of adulthood nutritional imbalance is shifting from a predominance of undernutrition to overnutrition. This complex problem poses a huge challenge to governments, non-state actors, and individuals desirous of addressing the problem of malnutrition in LMICs. The objective of this study was to systematically review the literature towards providing an estimate of the prevalence of overweight and obesity among adult Ghanaians.

Methods

This study followed the recommendations outlined in the PRISMA statement. Searches were performed in PubMed, Science Direct, google scholar, Africa Journals Online (AJOL) and the WHO African Index Medicus database. This retrieved studies (published up to 31st March 2016) that reported overweight and obesity prevalence among Ghanaians. All online searches were supplemented by reference screening of retrieved papers to identify additional studies.

Results

Forty-three (43) studies involving a total population of 48,966 sampled across all the ten (10) regions of Ghana were selected for the review. Our analysis indicates that nearly 43% of Ghanaian adults are either overweight or obese. The national prevalence of overweight and obesity were estimated as 25.4% (95% CI 22.2–28.7%) and 17.1% (95% CI = 14.7–19.5%), respectively. Higher prevalence of overweight (27.2% vs 16.7%) and obesity (20.6% vs 8.0%) were estimated for urban than rural dwellers. Prevalence of overweight (27.8% vs 21.8%) and obesity (21.9% vs 6.0%) were also significantly higher in women than men. About 45.6% of adult diabetes patients in Ghana are either overweight or obese. At the regional level, about 43.4%, 36.9%, 32.4% and 55.2% of residents in Ashanti, Central, Northern and Greater Accra region, respectively are overweight or obese. These patterns generally mimic the levels of urbanization. Per studies’ publication years, consistent increases in overweight and obesity prevalence were observed in Ghana in the period 1998–2016.

Conclusions

There is a high and rising prevalence of overweight and obesity among Ghanaian adults. The possible implications on current and future population health, burden of chronic diseases, health care spending and broader economy could be enormous for a country still battling many infectious and parasitic diseases. Public health preventive measures that are appropriate for the Ghanaian context, culturally sensitive, cost-effective and sustainable are urgently needed to tackle this epidemic.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3901-4) contains supplementary material, which is available to authorized users.

Progress in pediatrics in 2015: choices in allergy, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, nephrology, neurology, nutrition, oncology and pulmonology

This review focuses key advances in different pediatric fields that were published in Italian Journal of Pediatrics and in international journals in 2015. Weaning studies continue to show promise for preventing food allergy. New diagnostic tools are available for identifying the allergic origin of allergic-like symptoms. Advances have been reported in obesity, short stature and autoimmune endocrine disorders. New molecules are offered to reduce weight gain and insulin-resistance in obese children. Regional investigations may provide suggestions for preventing short stature. Epidemiological studies have evidenced the high incidence of Graves' disease and Hashimoto's thyroiditis in patients with Down syndrome. Documentation of novel risk factors for celiac disease are of use to develop strategies for prevention in the population at-risk. Diagnostic criteria for non-celiac gluten sensitivity have been reported. Negative effect on nervous system development of the supernumerary X chromosome in Klinefelter syndrome has emerged. Improvements have been made in understanding rare diseases such as Rubinstein-Taybi syndrome. Eltrombopag is an effective therapy for immune trombocytopenia. Children with sickle-cell anemia are at risk for nocturnal enuresis. Invasive diseases caused by Streptococcus pyogenes are still common despite of vaccination. No difference in frequency of antibiotic prescriptions for acute otitis media between before the publication of the national guideline and after has been found. The importance of timing of iron administration in low birth weight infants, the effect of probiotics for preventing necrotising enterocolitis and perspectives for managing jaundice and cholestasis in neonates have been highlighted. New strategies have been developed to reduce the risk for relapse in nephrotic syndrome including prednisolone during upper respiratory infection. Insights into the pathophysiology of cerebral palsy, arterial ischemic stroke and acute encephalitis may drive advances in treatment. Recommendations on breastfeeding and complementary feeding have been updated. Novel treatments for rhabdomyosarcoma should be considered for paediatric patients. Control of risk factors for bronchiolitis and administration of pavilizumab for preventing respiratory syncytial virus infection may reduce hospitalization. Identification of risk factors for hospitalization in children with wheezing can improve the management of this disease. Deletions or mutations in genes encoding proteins for surfactant function may cause diffuse lung disease.

Inflammation and Nutritional Science for Programs/Policies and Interpretation of Research Evidence (INSPIRE)

An increasing recognition has emerged of the complexities of the global health agenda—specifically, the collision of infections and noncommunicable diseases and the dual burden of over- and undernutrition. Of particular practical concern are both 1) the need for a better understanding of the bidirectional relations between nutritional status and the development and function of the immune and inflammatory response and 2) the specific impact of the inflammatory response on the selection, use, and interpretation of nutrient biomarkers. The goal of the Inflammation and Nutritional Science for Programs/Policies and Interpretation of Research Evidence (INSPIRE) is to provide guidance for those users represented by the global food and nutrition enterprise. These include researchers (bench and clinical), clinicians providing care/treatment, those developing and evaluating programs/interventions at scale, and those responsible for generating evidence-based policy. The INSPIRE process included convening 5 thematic working groups (WGs) charged with developing summary reports around the following issues: 1) basic overview of the interactions between nutrition, immune function, and the inflammatory response; 2) examination of the evidence regarding the impact of nutrition on immune function and inflammation; 3) evaluation of the impact of inflammation and clinical conditions (acute and chronic) on nutrition; 4) examination of existing and potential new approaches to account for the impact of inflammation on biomarker interpretation and use; and 5) the presentation of new approaches to the study of these relations. Each WG was tasked with synthesizing a summary of the evidence for each of these topics and delineating the remaining gaps in our knowledge. This review consists of a summary of the INSPIRE workshop and the WG deliberations.