Helicobacter pylori infection is associated with fecal biomarkers of environmental enteric dysfunction but not with the nutritional status of children living in Bangladesh

Background

Because Helicobacter pylori (H. pylori) infection and Environmental Enteric Dysfunction (EED) follow a similar mode of transmission, there can be a complex interplay between H. pylori infection and EED, both of which can influence childhood growth. We sought to investigate the factors associated with H. pylori infection and identify its relationship with the fecal biomarkers of EED including Myeloperoxidase (MPO), Neopterin (NEO), Calprotectin, Reg1B and Alpha-1 antitrypsin (AAT), and nutritional status of the children.

Methodology

Data from an on-going community-based nutrition intervention study was used for this analysis. Total 319 children aged between 12–18 months were evaluated at enrolment and at the end of a 90-day nutrition intervention. Multivariable linear regression with generalized estimating equations was done to examine the association of H. pylori infection with stool biomarker of EED and nutritional status of the children.

Principal findings

One-fifth of the participants had H. pylori infection at both the time points, with 13.8% overall persistence. Children living in crowded households had higher odds of being infected by H. pylori (AOR = 2.02; 95% CI = 1.02, 4.10; p-value = 0.045). At enrolment, 60%, 99%, 69% and 85% of the stool samples were elevated compared to the reference values set for MPO, NEO, AAT and Calprotectin in the non-tropical western countries. The proportions reduced to 52%, 99%, 67%, and 77% for the same biomarkers after the nutrition intervention. Infection with H. pylori had significant positive association with fecal AAT concentrations (Coefficient = 0.26; 95% CI = 0.02, 0.49; p-value = 0.03) and inverse relationship with Reg1B concentrations measured in the stool samples (Coefficient = -0.32; 95% CI = -0.59, -0.05; p-value = 0.02). However, H. pylori infection was not associated with the indicators of childhood growth.

Conclusions

The study findings affirmed that the acquisition and persistence of H. pylori infection in the early years of life may exert an adverse impact on intestinal health, induce gut inflammation and result in increased intestinal permeability.

Infection with H. pylori, a substantial public health burden in the tropical countries, follows the similar mode of transmission analogous to Environmental Enteric Dysfunction (EED). There can be a complex interplay between H. pylori infection and EED–both of which can influence childhood growth–but the definite role of H. pylori infection contributing to EED and subsequent growth failure is poorly understood. In this study, the authors present data from an ongoing community-based nutrition intervention study and investigated the factors associated with H. pylori infection and identify its relationship with fecal biomarkers of EED and indicators of the nutritional status of the children hailing from a resource-poor urban settlement. They demonstrated the acquisition and persistence of H. pylori infection during early childhood. The study results also corroborate that infection with H. pylori had significant positive association with fecal Alpha-1 antitrypsin concentrations and an inverse relationship with Reg1B concentrations measured in stool samples of the children. The findings revealed in this study may contribute to a better understanding of the role of H. pylori infection in contributing to EED as well as alteration of gut function in the early years of life.

Metabolic maturation in the first 2 years of life in resource-constrained settings and its association with postnatal growths

Malnutrition continues to affect the growth and development of millions of children worldwide, and chronic undernutrition has proven to be largely refractory to interventions. Improved understanding of metabolic development in infancy and how it differs in growth-constrained children may provide insights to inform more timely, targeted, and effective interventions. Here, the metabolome of healthy infants was compared to that of growth-constrained infants from three continents over the first 2 years of life to identify metabolic signatures of aging. Predictive models demonstrated that growth-constrained children lag in their metabolic maturity relative to their healthier peers and that metabolic maturity can predict growth 6 months into the future. Our results provide a metabolic framework from which future nutritional programs may be more precisely constructed and evaluated.

A sparse covarying unit that describes healthy and impaired human gut microbiota development

Characterizing the organization of the human gut microbiota is a formidable challenge given the number of possible interactions between its components. Using a statistical approach initially applied to financial markets, we measured temporally conserved covariance among bacterial taxa in the microbiota of healthy members of a Bangladeshi birth cohort sampled from 1 to 60 months of age. The results revealed an “ecogroup” of 15 covarying bacterial taxa that provide a concise description of microbiota development in healthy children from this and other low-income countries, and a means for monitoring community repair in undernourished children treated with therapeutic foods. Features of ecogroup population dynamics were recapitulated in gnotobiotic piglets as they transitioned from exclusive milk feeding to a fully weaned state consuming a representative Bangladeshi diet.

Efficacy of a Green Banana-Mixed Diet in the Management of Persistent Diarrhea: Protocol for an Open-Labeled, Randomized Controlled Trial

Background

Diarrhea is the second-leading cause of death in children under 5 years of age. In low- and middle-income countries, 3%-20% of acute diarrheal episodes become persistent diarrhea (PD) (ie, duration ≥14 days), which results in 36%-56% of all diarrheal deaths. In Bangladesh, PD causes >25% of diarrhea-related deaths. Commensal gut microbiota dysbiosis is increasingly recognized in the pathogenesis of PD. Hospital-based management of PD requires a hospital stay, which increases the risk of infection and hospital costs. The higher cost of treatment and high case-fatality rates reiterate PD as an important public health problem. At the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), for the last two decades, a consensus-based guideline has been followed for PD. Observation has revealed that green banana helps in the resolution of diarrhea. However, no larger prospective study has been conducted to evaluate the efficacy of green banana in the management of PD among children older than 6 months of age.

Objective

Our objective is to assess the efficacy of full-strength rice suji (semolina) with and without green banana compared to three-quarter-strength rice suji in the management of PD in children aged 6-36 months at the Dhaka Hospital of the icddr,b.

Methods

This open-labeled, randomized controlled study aims to enroll a total of 145 children with PD who have not been improving on a diet of milk suji. Children will be randomized into three different diet-specific groups: full-strength rice suji containing green banana, full-strength rice suji alone, and three-quarter-strength rice suji. The primary outcome is the percentage of children who recovered from diarrhea by day 5.

Results

Recruitment and data collection began in December 2017 and were completed in November 2019. Results are expected by April 2020.

Conclusions

This study is expected to provide insights into the incorporation of green banana into the dietary management of PD. This would be the first study to investigate the role of microbiota and metabolomics in the pathogenesis of PD.

Trial Registration

ClinicalTrials.gov NCT03366740; https://clinicaltrials.gov/ct2/show/NCT03366740

International Registered Report Identifier (IRRID)

DERR1-10.2196/15759

Evidence of gut enteropathy and factors associated with undernutrition among slum-dwelling adults in Bangladesh

BACKGROUND

Adult undernutrition (BMI <18.5 kg/m2) is responsible for immune deficits, increased risk of disease burden, and higher rates of mortality. The prevalence of adult undernutrition in Bangladesh is substantial, but there have been few studies on the etiology of this condition for the inhabitants of urban slums.

OBJECTIVE

The aim of this study was to identify the factors associated with undernutrition among slum-dwelling adults in Bangladesh.

METHODS

A case-control study was conducted in the Bauniabadh area of Dhaka, Bangladesh. 270 adult participants (135 cases with a BMI <18.5 and 135 controls with a BMI between 18.5 and 24.9) aged 18-45 y were enrolled between October 2018 and January 2019. Sociodemographic variables, dietary diversity, micronutrient deficiencies, psychological symptoms, infection, and biomarkers of gut health were assessed to identify the factors associated with undernutrition using multivariable logistic regression analysis.

RESULTS

A higher number of siblings [adjusted odds ratio (aOR): 1.39; 95% CI: 1.11, 1.77], increased self-reporting questionnaire-20 score (an instrument to screen mental health disorders and detect psychological symptoms) (aOR: 1.12; 95% CI: 1.04, 1.23), elevated fecal concentration of α-1 antitrypsin (aOR: 4.82; 95% CI: 1.01, 25.29), and anemia (aOR: 3.63; 95% CI: 1.62, 8.58) were positively associated with undernutrition in adults. Age (aOR: 0.90; 95% CI: 0.84, 0.96), dietary diversity score (aOR: 0.75; 95% CI: 0.56, 0.99), C-reactive protein (aOR: 0.82; 95% CI: 0.73, 0.92), Helicobacter pylori infection (aOR: 0.11; 95% CI: 0.05, 0.23), and always washing hands before eating or preparing foods (aOR: 0.33; 95% CI: 0.12, 0.87) were associated with reduced odds of undernutrition among the study population.

CONCLUSIONS

Our results indicate that undernutrition in slum-dwelling adults in Bangladesh is associated with numerous physiological and sociodemographic factors, including evidence of gastrointestinal inflammation and altered intestinal permeability.

Dietary Magnesium, Vitamin D, and Animal Protein Intake and Their Association to the Linear Growth Trajectory of Children from Birth to 24 Months of Age: Results From MAL-ED Birth Cohort Study Conducted in Dhaka, Bangladesh

BACKGROUND

Evidence suggests lack of understanding of the association of specific nutrients with different time points of linear growth trajectory.

OBJECTIVE

We investigated the role of dietary macro- and micronutrients on length-for-age z (LAZ) score trajectory of children across first 24 months of their life.

METHODS

The MAL-ED Bangladesh birth cohort study recruited 265 healthy newborn children after birth. The linear growth trajectory of those children was modeled using latent growth curve modeling (LGCM) technique.

RESULTS

Dietary magnesium intake at 9 to 11 months was positively associated (coefficient β = 0.006, P < .02) with LAZ at 12 months. Animal protein intake at 15 to 17 months, in turn, was positively associated (β = 0.03, P < .03) with LAZ at 18 months. However, vitamin D intake at 15 to 17 months was negatively associated (β = -0.06, P < .02) with LAZ at 18 months. Other micro- and macronutrients did not show any statistically significant association with the linear growth trajectory. We also found that birth weight (β = 0.91, P < .01), treating water (β = 0.35, P < 0.00), and maternal height (β = 3.4, P < .00) were positively associated with intercept. Gender had a significant negative association with the intercept, but a positive association with the slope (β = -0.39, P < .01; β = 0.08, P < .04), respectively. Conversely, birth weight had negative association with the slope (β = -0.12, P < .01).

CONCLUSIONS

Dietary magnesium and animal protein were positively and vitamin D was negatively associated with the linear growth trajectory. Maternal height, birth weight, gender, and treatment of drinking water also played significant roles in directing the trajectory.

Daily Supplementation With Egg, Cow Milk, and Multiple Micronutrients Increases Linear Growth of Young Children with Short Stature

BACKGROUND

Childhood stunting is the most prevalent public health nutrition problem in low- and middle-income countries.

OBJECTIVE

This study aimed to determine whether daily supplementation in 12-18-mo-old undernourished Bangladeshi children with egg, cow milk, and multiple micronutrients improves linear growth.

METHODS

In the Bangladesh Environmental Enteric Dysfunction (BEED) study, a community-based intervention study, 12-18-mo-old children with length-for-age z score (LAZ) <1 were supplemented daily with an egg and 150 mL of milk for 90 feeding days, and 1 sachet of multiple micronutrient powder was provided daily for 60 feeding days. The change in LAZ over this period was compared with that in children of the same age and same baseline LAZ who were enrolled in the recently completed Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health (MAL-ED) Dhaka birth cohort study conducted in the same community where no nutrition intervention was provided. Difference-in-difference (DID) analysis was done and the effect size was adjusted for other possible covariates using a generalized estimating equation in a regression model.

RESULTS

A total of 472 children with LAZ <1 completed the intervention and data were available for 174 children in the comparison group. Compared with the comparison group, adjusted DID analysis revealed a change in LAZ in the intervention group of +0.23 (95% CI: 0.18, 0.29; P < 0.05). In a subgroup analysis, the changes were +0.27 (95% CI: 0.18, 0.35; P < 0.05) in stunted (LAZ <2) children and +0.19 (95% CI: 0.12, 0.27; P < 0.05) in children at risk of stunting (LAZ -1 to -2). No allergic reactions or other adverse events related to milk and egg consumption were observed.

CONCLUSIONS

Daily directly observed milk, egg, and multiple micronutrient supplementation may improve linear growth of stunted children. A randomized controlled trial with longer duration of supplementation coupled with an additional intervention aimed at reducing pathogen burden is warranted to confirm these results. This trial was registered at clinicaltrials.gov as NCT02812615.

Impact of early-onset persistent stunting on cognitive development at 5 years of age: Results from a multi-country cohort study

Background

Globally more than 150 million children under age 5 years were stunted in 2018, primarily in low- and middle-income countries (LMICs), and the impact of early-onset, persistent stunting has not been well explored. To explore the association between early-onset persistent stunting in children and cognitive development at 5 years of age, and to identify the factors associated with early-onset stunting.

Methods and findings

Children from the MAL-ED cohort study were followed from birth to 5 years of age in six LMICs. The Wechsler Preschool Primary Scales of Intelligence (WPPSI) was used to assess cognitive abilities (fluid reasoning) at 5 years and was adapted for each culture. Stunting was categorized as early-onset persistent (first stunted at 1–6 months and persisting at 60 months), early-onset recovered (first stunted at 1–6 months and not stunted at 60 months), late-onset persistent (first stunted at 7–24 months and persisting at 60 months), late-onset recovered (first stunted at 7–24 months and not stunted at 60 months), and never (never stunted). Mixed effects linear models were used to estimate the relationship between stunting status and cognitive development. Children with early-onset persistent stunting had significantly lower cognitive scores (-2.10 (95% CI: -3.85, -0.35)) compared with those who were never stunted. Transferrin receptor (TfR) was also negatively associated with cognitive development (-0.31 (95% CI: -0.49, -0.13)), while the HOME inventory, an index of quality of the home environment (0.46 (95% CI: 0.21, 0.72)) and socio-economic status (1.50 (95% CI: 1.03, 1.98)) were positively associated with cognitive development.

Conclusions

Early-onset persistent stunting was associated with lower cognitive development in children at 5 years of age in this cohort of children.

Why Do Children in Slums Suffer from Anemia, Iron, Zinc, and Vitamin A Deficiency? Results from a Birth Cohort Study in Dhaka

Considering the high burden of micronutrient deficiencies in Bangladeshi children, this analysis aimed to identify the factors associated with micronutrient deficiencies and association of plasma micronutrient concentration trajectories from 7 to 24 months with the concentrations at 60 months of age. Plasma samples were collected at 7, 15, 24, and 60 months of age, and hemoglobin, ferritin, zinc, and retinol concentrations of 155, 153, 154, and 155 children were measured, respectively. A generalized estimating equation was used to identify the factors associated with micronutrient deficiencies, while latent class growth modeling identified the trajectories of plasma micronutrients from 7 to 24 months and its association with the concentrations of micronutrients at 60 months was examined using multiple linear regression modeling. Early (AOR = 2.21, p < 0.05) and late convalescence (AOR = 1.65, p < 0.05) stage of an infection, low ferritin (AOR = 3.04, p < 0.05), and low retinol (AOR = 2.07, p < 0.05) were associated with increased anemia prevalence. Wasting at enrollment was associated with zinc deficiency (AOR = 1.8, p < 0.05) and birth weight was associated with ferritin deficiency (AOR = 0.58, p < 0.05). Treatment of drinking water was found protective against vitamin A deficiency (AOR = 0.57, p < 0.05). Higher trajectories for ferritin and retinol during 7–24 months were positively associated with plasma ferritin (β = 13.72, p < 0.05) and plasma retinol (β = 3.99, p < 0.05) at 60 months.

Determinants of Campylobacter infection and association with growth and enteric inflammation in children under 2 years of age in low-resource settings

Campylobacter species infections have been associated with malnutrition and intestinal inflammation among children in low-resource settings. However, it remains unclear whether that association is specific to Campylobacter jejuni/coli. The aim of this study was to assess the association between both all Campylobacter species infections and Campylobacter jejuni/coli infections on growth and enteric inflammation in children aged 1-24 months. We analyzed data from 1715 children followed from birth until 24 months of age in the MAL-ED birth cohort study, including detection of Campylobacter species by enzyme immunoassay and Campylobacter jejuni/coli by quantitative PCR in stool samples. Myeloperoxidase (MPO) concentration in stool, used as a quantitative index of enteric inflammation, was measured. The incidence rate per 100 child-months of infections with Campylobacter jejuni/coli and Campylobacter species during 1-24 month follow up were 17.7 and 29.6 respectively. Female sex of child, shorter duration of exclusive breastfeeding, lower maternal age, mother having less than 3 living children, maternal educational level of <6 years, lack of routine treatment of drinking water, and unimproved sanitation were associated with Campylobacter jejuni/coli infection. The cumulative burden of both Campylobacter jejuni/coli infections and Campylobacter species were associated with poor growth and increased intestinal inflammation.

Impact of negative tuberculin skin test on growth among disadvantaged Bangladeshi children

Millions of children are suffering from tuberculosis (TB) worldwide and often end-up with fatal outcome especially in resource-poor settings. Tuberculin skin test (TST) is a conventionally used diagnostic test, less sensitive but highly specific for the diagnosis of clinical TB especially in undernourished children. However, we do not have any data on the role of TST positivity among the children who received nutritional intervention. Our aim was to examine the growth differences between TST-positive and TST-negative undernourished children aged 12 to 18 months who received nutritional intervention prospectively for 90 feeding days. Our further aim was to explore the determinants of TST positivity at enrollment. TB screening as one of the secondary causes of malnutrition was performed on 243 stunted [length for age Z score (LAZ) <-2 standard deviations] or at-risk of stunting (LAZ score between <-1 and -2 standard deviations) children in a community-based intervention study designed to improve their growth parameters. Differences of growth between TST-positives (n = 29) and TST-negatives (n = 214) were compared using paired samples t-test and multivariable linear regression from anthropometric data collected before and after nutritional intervention. Multivariable logistic regression was used to find out possible predictors of TST positivity using baseline sociodemographic data. Of the 243 children screened, 29 (11.9%) were TST-positive and 11 (4.5%) had clinically diagnosed pulmonary TB. Statistically significant improvement of LAZ and weight for age Z-score (WAZ) were observed among the TST-negative participants at the end of intervention period (p = 0.03 for LAZ and p = 0.01 for WAZ). However, we did not find any association between TST status and response to nutritional intervention in our multivariable linear regression models. Our study findings demonstrated a positive impact of nutritional intervention on growth parameters among TST-negative participants.

Epidemiology and Risk Factors for Cryptosporidiosis in Children From 8 Low-income Sites: Results From the MAL-ED Study

Background

Cryptosporidium species are enteric protozoa that cause significant morbidity and mortality in children worldwide. We characterized the epidemiology of Cryptosporidium in children from 8 resource-limited sites in Africa, Asia, and South America.

Methods

Children were enrolled within 17 days of birth and followed twice weekly for 24 months. Diarrheal and monthly surveillance stool samples were tested for Cryptosporidium by enzyme-linked immunosorbent assay. Socioeconomic data were collected by survey, and anthropometry was measured monthly.

Results

Sixty-five percent (962/1486) of children had a Cryptosporidium infection and 54% (802/1486) had at least 1 Cryptosporidium-associated diarrheal episode. Cryptosporidium diarrhea was more likely to be associated with dehydration (16.5% vs 8.3%, P < .01). Rates of Cryptosporidium diarrhea were highest in the Peru (10.9%) and Pakistan (9.2%) sites. In multivariable regression analysis, overcrowding at home was a significant risk factor for infection in the Bangladesh site (odds ratio, 2.3 [95% confidence interval {CI}, 1.2-4.6]). Multiple linear regression demonstrated a decreased length-for-age z score at 24 months in Cryptosporidium-positive children in the India (β = -.26 [95% CI, -.51 to -.01]) and Bangladesh (β = -.20 [95% CI, -.44 to .05]) sites.

Conclusions

This multicountry cohort study confirmed the association of Cryptosporidium infection with stunting in 2 South Asian sites, highlighting the significance of cryptosporidiosis as a risk factor for poor growth. We observed that the rate, age of onset, and number of repeat infections varied per site; future interventions should be targeted per region to maximize success.

Ascaris lumbricoides infection: Still a threat for iron deficiency anaemia in 2-year-old Bangladeshi slum-dwelling children

INTRODUCTION

Although parasitic infections lead to extracorporeal iron loss resulting in iron deficiency anaemia (IDA), data associating IDA with parasitic infections in the first two years of life are limited. We sought to evaluate the prevalence and severity of anaemia and IDA during this period and to investigate the association between intestinal parasitic infections and IDA.

METHODOLOGY

Data was collected under MAL-ED study protocol in Bauniabadh slum of Dhaka, Bangladesh. The presence of parasites in stool was detected using wet preparation microscopy at 7, 15, and 24 months. Anaemia was defined as serum haemoglobin < 11 g/dL and IDA was defined by serum haemoglobin < 11 g/dL, serum ferritin < 12 g/L and soluble transferrin receptor > 8.3 mg/L. Logistic regression was done to quantify the relation between stool parasite and IDA separately on samples collected at 7, 15 and 24 months.

RESULTS

265 children were enrolled after birth and samples were collected at 7, 15 and 24 months. Anaemia was detected at 7, 15 and 24 months in 117 (48.8%), 106 (44.2%) and 67 (27.9%) cases whereas IDA was found in 15 (6.3%), 47 (19.6%) and 39 (16.3%) cases, respectively. Iron deficiency anaemia at 24 months was significantly associated with Ascaris lumbricoides infection (OR 3.76; 95 % CI, 1.08-13.11).

CONCLUSIONS

The prevalence of anaemia and IDA in slum dwelling children of Dhaka is high and Ascaris lumbricoides infection was found to have a strong association with IDA at 24 months of age.

Impact of Small Intestine Bacterial Overgrowth on Response to a Nutritional Intervention in Bangladeshi Children from an Urban Community

Small intestine bacterial overgrowth (SIBO) is prevalent among children living in low-income settings, leading to impaired growth and development. The aim of this study was to assess linear and ponderal growth parameters between malnourished SIBO-positive and SIBO-negative children aged 12-18 months who prospectively underwent a nutritional intervention. A glucose hydrogen breath test to detect SIBO was performed in 194 stunted (length-for-age Z score [LAZ] < -2 standard deviations) or at-risk of stunting (LAZ score between < -1 and -2 standard deviations) children. Participants received nutritional supplementation (egg and milk) in addition to their regular family meals 6 days per week for 90 days. Small intestine bacterial overgrowth was defined as a ≥ 12-ppm rise in breath hydrogen over the patient's baseline during the 3-hour test. Small intestine bacterial overgrowth status before intervention was forced into a multivariable linear regression model to examine its effects on anthropometric changes in response to the intervention. Sociodemographic data at enrollment was analyzed through multivariable logistic regression in an attempt to predict SIBO positivity. Overall, 14.9% (29/194) children were diagnosed with SIBO before the nutritional intervention. No statistically significant difference was observed among SIBO-positive and SIBO-negative groups in terms of their response to the nutritional intervention (SIBO-positive coefficient [95% confidence interval (CI)], P-value for ∆length-for-age Z score -0.003 [-0.14, 0.13], 0.96; ∆weight-for-age Z score -0.05 [-0.20, 0.09], 0.46; and ∆weight-for-length Z score -0.10 [-0.31, 0.10], 0.33). This study demonstrated that a noteworthy proportion of malnourished children living in a disadvantaged urban community were SIBO positive; however, it failed to reveal an association between SIBO status and response to nutritional intervention.

Intestinal permeability and inflammation mediate the association between nutrient density of complementary foods and biochemical measures of micronutrient status in young children: results from the MAL-ED study

BACKGROUND

Environmental enteric dysfunction (EED) is thought to increase the risk of micronutrient deficiencies, but few studies adjust for dietary intakes and systemic inflammation.

OBJECTIVE

We tested whether EED is associated with micronutrient deficiency risk independent of diet and systemic inflammation, and whether it mediates the relation between intake and micronutrient status.

METHODS

Using data from 1283 children in the MAL-ED (Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health) birth cohort we evaluated the risk of anemia, low retinol, zinc, and ferritin, and high transferrin receptor (TfR) at 15 mo. We characterized gut inflammation and permeability by myeloperoxidase (MPO), neopterin (NEO), and α-1-antitrypsin (AAT) concentrations from asymptomatic fecal samples averaged from 9 to 15 mo, and averaged the lactulose:mannitol ratio z-score (LMZ) at 9 and 15 mo. Nutrient intakes from complementary foods were quantified monthly from 9 to 15 mo and densities were averaged for analyses. α-1-Acid glycoprotein at 15 mo characterized systemic inflammation. Relations between variables were modeled using a Bayesian network.

RESULTS

A greater risk of anemia was associated with LMZ [1.15 (95% CI: 1.01, 1.31)] and MPO [1.16 (1.01, 1.34)]. A greater risk of low ferritin was associated with AAT [1.19 (1.03, 1.37)] and NEO [1.22 (1.04, 1.44)]. A greater risk of low retinol was associated with LMZ [1.24 (1.08, 1.45)]. However, MPO was associated with a lower risk of high transferrin receptor [0.86 (0.74, 0.98)], NEO with a lower risk of low retinol [0.75 (0.62, 0.89)], and AAT with a lower risk of low plasma zinc [0.83 (0.70, 0.99)]. Greater nutrient intake densities (vitamins A and B6, calcium, protein, and zinc) were negatively associated with EED. Inverse associations between nutrient densities and micronutrient deficiency largely disappeared after adjustment for EED, suggesting that EED mediates these associations.

CONCLUSIONS

EED is independently associated with an increased risk of low ferritin, low retinol, and anemia. Greater nutrient density from complementary foods may reduce EED, and the control of micronutrient deficiencies may require control of EED.

Association of faecal pH with childhood stunting: Results from a cross-sectional study

BACKGROUND

Gut microbiota plays an important role in the growth of children. The gut of children with optimum growth is enriched in certain species, especially Bifidobacteria and Clostridia. Bifidobacteria and commensal Clostridia both contribute to formation of acidic stool, and an elevated faecal pH indicates reduction of these species in the gut. The purpose of the study was to investigate the association of faecal pH with childhood stunting.

METHODS

In this cross-sectional study, 100 children with length-for-age Z score (LAZ) <-1 aged between 12 and 18 months were enrolled from the ongoing Bangladesh Environmental Enteric Dysfunction study conducted in Dhaka, Bangladesh. LAZ was measured by anthropometry and data on factors affecting linear growth were recorded. Faecal pH measurement was done using pH metre on freshly collected non-diarrhoeal faecal samples following standard procedure. Multiple quantile regression was done to quantify the relation between faecal pH and LAZ scores.

RESULTS

The mean LAZ and faecal pH of the children were -2.12±0.80 and 5.84±1.11, respectively. Pearson correlation analysis showed a statistically significant negative correlation between stool pH and the LAZ scores (p<0.01). After inclusion of other factors affecting linear growth into the regression model, a statistically significant inverse association was observed between faecal pH and LAZ score (p<0.01).

CONCLUSION

Elevated faecal pH was found to have a significant association with stunted growth. As an indicator of gut microbiota status, faecal pH might have emerged as a possible indirect determinant of childhood stunting.

TRIAL REGISTRATION NUMBER

NCT02812615.

Aflatoxin exposure in children living in Mirpur, Dhaka: data from MAL-ED companion study

Dietary exposure to aflatoxin is implicated in growth faltering of children. Despite the high burden of childhood stunting in urban Bangladesh, there are no data on long-term exposure to aflatoxin. This study aimed to explore aflatoxin exposure levels in a group of children followed longitudinally. The current study used data and biospecimens collected during 2010-2014 as part of the MAL-ED birth cohort study in an urban slum of Mirpur, Dhaka where children were followed from birth to 36 months. AFB1-lysine adduct concentrations were determined by isotope dilution mass spectrometry from plasma samples collected at 7, 15, 24, and 36 months of age. The limit of detection was 0.5 pg of AFB1-lys/mg albumin. In 744 plasma samples, the geometric mean of AFB1-lysine/mg albumin was 1.07 pg (range 0.04-123.5 pg/mg albumin). The proportion of children with detectable aflatoxin exposure was 10.1, 20.9, 17.9, and 61.7% for 7, 15, 24, and 36 months, respectively. Reduction in breastfeeding prevalence (80% at 24 months vs. 38% in 36 months) corresponded with the high-level detection of AFB1-lysine at the age of 36 months. AFB1-lysine concentrations were the highest at the end of monsoon. This study reveals that 62% of children in slum settlement were exposed to aflatoxin by the end of the third year of life. High aflatoxin exposure was detected at the end of rainy season and with the introduction of family food. These findings suggest interventions to ameliorate the problem of chronic aflatoxin exposure including childhood stunting.

Measurement of intestinal permeability using lactulose and mannitol with conventional five hours and shortened two hours urine collection by two different methods: HPAE-PAD and LC-MSMS

Urinary excretion of two orally-administered non-metabolizable sugars, lactulose and mannitol, is a valuable marker for evaluating intestinal permeability. Usually this test involves a time consuming procedure of about 5 hour’s urine collection, which makes the test incompatible to some extent. As the results are expressed as the ratio of lactulose and mannitol recovered in urine within certain time, it may be possible to get similar result despite the reduced urine collection time of 2 hours. Moreover, different laboratories do the test by different methods, which make the results incomparable between laboratories. Here, we are also trying to find the correlation between results from most commonly used methods: HPAE-PAD and LC-MSMS. The lactulose: mannitol (LM) test was performed in a cohort of Bangladeshi infants considered at-risk for environmental enteropathy. 208 urine specimens from 104 (52 male and 52 female) infants were collected at 2 and 5 hours after LM solution administration and were tested for lactulose and mannitol by two different methods, one HPAE-PAD platform and another LC-MSMS platform. Median age of the children was 15.0 months (range 6.9 to 25.8 months) and their mean weight-for-age z-score was -0.92. A higher percentage of lactulose and mannitol recovery was found in 5 hours urine collection than in the corresponding 2 hours by both HPAE-PAD and LC-MSMS method, but when results were expressed as lactulose to mannitol ratio (LMR) there was no significant difference between 2 and 5 hours urine collection in both HPAE-PAD (P = 0.138) and LC-MSMS (P = 0.099) method. LMR based on 2 hours urine collection correlated well with LMR based on traditional 5 hours urine collection (Spearman’s correlation coefficient 0.578 and 0.604 respectively for HPAE-PAD and LC-MSMS). In future, LM test to assess intestinal permeability in children can be simplified by shortening the urine collection time from 5 hours to 2 hours.

Serum Adipokines, Growth Factors, and Cytokines Are Independently Associated with Stunting in Bangladeshi Children

Growth in young children is controlled through the release of several hormonal signals, which are affected by diet, infection, and other exposures. Stunting is clearly a growth disorder, yet limited evidence exists documenting the association of different growth biomarkers with child stunting. This study explored the association between different growth biomarkers and stunting in Bangladeshi children. A quasi-experimental study was conducted among 50 stunted (length-for-age Z-score (LAZ) < -2 SD) and 50 control (LAZ ≥ -2 SD) children, aged 12-18 months, residing in a Bangladeshi slum. The enrolled stunted children received an intervention package, which included food supplementation for three months, psychosocial stimulation for six months, and routine clinical care on community nutrition center at the study field site. The controls received routine clinical care only. All children were clinically screened over the study period. Length, weight, fasting blood and fecal biomarkers were measured. All biomarkers levels were similar in both groups except for oxyntomodulin at enrolment. Leptin (adjusted odds ratio, AOR: 4.0, p < 0.01), leptin-adiponectin ratio (AOR 5.07 × 10⁸, p < 0.01), insulin-like growth factor-1 (IGF-1) (AOR 1.02, p < 0.05), and gamma interferon (IFN-γ) (AOR 0.92, p < 0.05) levels were independently associated with stunting at enrolment. Serum leptin, leptin-adiponectin ratio, interleukin-6 (IL-6), IL-10, tumor necrosis factor-alpha (TNF-α), and fecal alpha-1-antitrypsin (AAT) levels increased significantly (p < 0.001), while IFN-γ levels significantly decreased among stunted children after six months of intervention. Leptin, leptin-adiponectin ratio, IGF-1, and IFN-γ are independently associated with stunting in Bangladeshi children. This trial was registered at clinicaltrials.gov as NCT02839148.

Early childhood development and stunting: Findings from the MAL-ED birth cohort study in Bangladesh

Information on the association between stunting and child development is limited from low‐income settings including Bangladesh where 36% of children under‐ 5 are stunted. This study aimed to explore differences in early childhood development (ECD) between stunted (length‐for‐age z‐score [LAZ] < −2) and nonstunted (LAZ ≥ −2) children in Bangladesh. Children (n = 265) aged 6–24 months who participated in the MAL‐ED birth cohort study were evaluated by trained psychologists at 6, 15, and 24 months of age using the Bayley Scales of Infant and Toddler Development‐III; child length and weight were measured using standard procedures. ECD scores (z‐scores derived from cognitive, motor, language and socio‐emotional skills) were compared between stunted, underweight (weight‐for‐age z‐score < −2), and wasted (weight‐for‐length z‐score < −2) children, controlling for child age and sex and maternal age, education, body mass index (BMI), and depressive symptoms. Stunted children had significantly lower ECD scores than their nonstunted peers on cognitive (P = .049), motor (P < .001), language (P < .001) and social–emotional (P = .038) scales where boys had significantly lower fine motor skills compared with girls (P = .027). Mother's schooling and BMI were significant predictors of ECD. Similar to stunting, underweight children had developmental deficits in all domains (cognitive: P = .001; fine motor: P = .039, and P < .001 for both gross motor and total motor; expressive communication: P = .032; total language: P = .013; social–emotional development: P = .017). Wasted children had poor motor skills (P = .006 for the fine motor; P < .001 for both gross motor and total motor development) compared with the nonwasted peers. Early childhood stunting and underweight were associated with poor developmental outcomes in Bangladesh.

Relative contributions of the correlates of stunting in explaining the mean length-for-age z-score difference between 24-month-old stunted and non-stunted children living in a slum of Dhaka, Bangladesh: results from a decomposition analysis

OBJECTIVE

Using MAL-ED (Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health) Bangladesh birth cohort data, we sought to measure the relative contributions of the most predictive correlates of stunting to mean length-for-age z (LAZ) score difference between stunted and non-stunted children at 24 months of age.

SETTING

Dhaka, Bangladesh PARTICIPANTS: 211 slum-dwelling children enrolled within 17 days of their birth.

VARIABLES AND METHOD

The explanatory variables were identified from the following groups: maternal characteristics, birth characteristics, macronutrient intake, socioeconomic status, morbidity and serum micronutrient level. At step 1, predictive correlates of stunting were identified longitudinally (from 9 to 24 months of age) using generalized estimating equations (GEE) model. Then, the relative contributions of the most predictive correlates of stunting to mean LAZ score difference between stunted and non-stunted children at 24 months of age was measured using Blinder-Oaxaca decomposition analysis RESULTS: The GEE multivariable model identified maternal height, birth weight, people per room, gender, having separate room for kitchen and energy intake as the most predictive correlates of stunting. At 24 months, mean LAZ score difference between stunted and non-stunted children was 1.48. The variable by variable decomposition of the LAZ gap identified maternal height (coefficient: -3.04; 95% CI: 0.35 to -6.44), birth weight (coefficient: -0.21; 95% CI: 0.88 to -1.30), people per room (coefficient: 0.31; 95% CI: 0.92 to -0.30) and energy intake (coefficient: -0.12; 95% CI: 0.22 to -0.46) as the top most factors responsible for the mean LAZ score difference between stunted and non-stunted children at 24 months of age.

CONCLUSIONS

The relative contributions of maternal height and birth weight to LAZ gap signifies that improvement in nutritional status of a women during her adolescence and pregnancy would have an impact on birth weight of her offspring, and ultimately, on linear growth of the child.

Effects of microbiota-directed foods in gnotobiotic animals and undernourished children

To examine the contributions of impaired gut microbial community development to childhood undernutrition, we combined metabolomic and proteomic analyses of plasma samples with metagenomic analyses of fecal samples to characterize the biological state of Bangladeshi children with severe acute malnutrition (SAM) as they transitioned, after standard treatment, to moderate acute malnutrition (MAM) with persistent microbiota immaturity. Host and microbial effects of microbiota-directed complementary food (MDCF) prototypes targeting weaning-phase bacterial taxa underrepresented in SAM and MAM microbiota were characterized in gnotobiotic mice and gnotobiotic piglets colonized with age- and growth-discriminatory bacteria. A randomized, double-blind controlled feeding study identified a lead MDCF that changes the abundances of targeted bacteria and increases plasma biomarkers and mediators of growth, bone formation, neurodevelopment, and immune function in children with MAM.

Enteric dysfunction and other factors associated with attained size at 5 years: MAL-ED birth cohort study findings

BACKGROUND

Poor growth in early childhood has been associated with increased risk of mortality and morbidity, as well as long-term deficits in cognitive development and economic productivity.

OBJECTIVES

Data from the MAL-ED cohort study were used to identify factors in the first 2 y of life that are associated with height-for-age, weight-for-age, and body mass index z-scores (HAZ, WAZ, BMIZ) at 5 y of age.

METHODS

A total of 1017 children were followed from near birth until 5 y of age at sites in Bangladesh, Brazil, India, Nepal, Peru, South Africa, and Tanzania. Data were collected on their growth, environmental enteric dysfunction (EED), micronutrient status, enteric pathogen burden, illness prevalence, dietary intake, and various other socio-economic and environmental factors.

RESULTS

EED biomarkers were related to size at 5 y. Mean lactulose:mannitol z-scores during the first 2 y of life were negatively associated with all of the growth measures (HAZ: -0.11 [95% CI: -0.19, -0.03]; WAZ: -0.16 [95% CI: -0.26, -0.06]; BMIZ: -0.11 [95% CI: -0.23, 0.0]). Myeloperoxidase was negatively associated with weight (WAZ: -0.52 [95% CI: -0.78, -0.26] and BMIZ: -0.56 [95% CI: -0.86, -0.26]); whereas α-1-antitrypsin had a negative association with HAZ (-0.28 [95% CI: -0.52, -0.04]). Transferrin receptor was positively related to HAZ (0.18 [95% CI: 0.06, 0.30]) and WAZ (0.21 [95% CI: 0.07, 0.35]). Hemoglobin was positively related to HAZ (0.06 [95% CI: 0.00, 0.12]), and ferritin was negatively related to HAZ (-0.08 [95% CI: -0.12, -0.04]). Bacterial density in stool was negatively associated with HAZ (-0.04 [95% CI: -0.08, 0.00]), but illness symptoms did not have any effect on size at 5 y.

CONCLUSIONS

EED markers, bacterial density, and iron markers are associated with growth at 5 y of age. Interventions to reduce bacterial burden and EED may improve long-term growth in low-income settings.

Plasma Fibroblast Growth Factor 21 Is Associated with Subsequent Growth in a Cohort of Underweight Children in Bangladesh

BACKGROUND

Current nutritional intervention strategies have not proven effective in improving childhood ponderal and linear growth in underweight and stunted children. Novel markers are needed to classify children who are likely to respond to available interventions and to identify those requiring additional interventions. Fibroblast Growth Factor 21 (FGF21), an endocrine hormone that regulates metabolism and growth during periods of reduced protein intake, may be useful in this context.

OBJECTIVES

We aimed to determine the associations between plasma FGF21 concentrations and subsequent growth, and the association between change in FGF21 concentrations and concurrent growth, in children receiving nutritional supplementation.

METHODS

A total of 120 children between ages 6 and 13 mo with weight-for-age z score (WAZ) between -3 and -2 were enrolled from an urban slum in Dhaka, Bangladesh. Children received 376-kcal feeding supplements daily for 5 mo and were followed for 5 additional mo. FGF21 was measured in plasma collected at enrollment and month 5. FGF21 values that fell above the 90th percentile of baseline concentrations (1056.5 pg/mL) were considered high. Linear regression was used to examine the association between baseline FGF21 status and 5-mo change in WAZ and length-for-age z score (LAZ), and the association between 5-mo change in FGF21 and concurrent WAZ and LAZ change.

RESULTS

The median baseline FGF21 concentration was 241.4 pg/mL (IQR: 111.7, 451.3 pg/mL). On average, children with high baseline FGF21 gained 0.58 WAZ (95% CI: 0.28, 0.88) and 0.54 LAZ (95% CI: 0.23, 0.84) more during supplementation than those with low values. Change in FGF21 concentration during supplementation was negatively associated with change in WAZ (-0.48; 95% CI: -0.67, -0.29) and LAZ (-0.31; 95% CI: -0.52, -0.11).

CONCLUSIONS

FGF21 may be a useful marker of growth faltering and may allow identification of children who are more or less likely to respond to nutritional supplementation. This trial was registered at clinicaltrials.gov as NCT02441426.

Screening for coeliac disease in children and adults living in a slum of Dhaka, Bangladesh

Background and objective

Serological screening with a confirmation through biopsy has improved the understanding of coeliac disease (CD) epidemiology worldwide. Prevalence of CD in Bangladesh is not yet explored and therefore, we aimed to assess the seroprevalence of CD in slum-dwelling malnourished children and adults in Dhaka.

Methods

Serum samples were collected from three different cohorts: stunted (length-for-age Z-scores (LAZ) <−2) and at risk of stunting children (LAZ <−1 to −2) and malnourished adults (body mass index <18.5 kg/m²). Samples from all the participants were assessed for anti-tissue transglutaminase antibody (tTG-IgA) and total serum IgA by ELISA. Positive tTG-IgA and randomly selected low IgA values were reconfirmed using anti-tTG-IgG and gliadin IgG ELISA. CD was diagnosed when second screening tests were found positive and the participants were further investigated by small bowel biopsy.

Results

A total of 818 participants (240 stunted, 272 at risk of stunting children and 306 malnourished adults) were enrolled in the study. Overall, anti-tTG-IgA was positive in 5/818 (0.6%; 95% CI 0.25% to 1.46%). Of the five positive cases, anti-tTG-IgG and gliadin IgG were found positive in only one participant. Duodenal biopsy of positive participant revealed characteristic lesions of CD. Randomly selected low IgA values were found negative in tTG-IgG and gliadin IgG for all the participants. No participant was found total IgA deficient.

Conclusion

The incidence of coeliac autoimmunity is low in malnourished slum dwellers regardless of age in Bangladesh. It is important to investigate the nationwide prevalence to reveal the definite picture.

Development and validation of a tool to assess appetite of children in low income settings

Reliable and validated tools for measuring appetite of children in South Asia are not available. This study aimed to develop and validate a tool for assessing appetite level of under-five children. Based on literature review and findings from focus group discussions (FGDs), an initial 27-item interview-based tool, the "Early Childhood Appetite and Satiety Tool (ECAST)" was developed in Bangladesh. Fourteen FGDs were carried out in rural and urban settings and constructs for inclusion were derived from the themes and coding of FGDs and appetite assessment tools used in Western contexts. For structural validation, the ECAST-27-was administered on 150 mothers/primary caregivers of children aged 6-59 months, living in urban and rural areas. To validate the association with other variables, the ECAST was administered on mothers of children aged 12-24 months in the community (N = 50), and two groups of wasted, hospitalized children (Weight-for-length, Z score <-2SD) [group1: twenty acutely ill children aged 6-59 months; group 2: twenty children in nutritional rehabilitation aged 18-24 months]. Reliability of ECAST was estimated using Cronbach's alpha and Pearson's correlation coefficient. Kaiser-Meyer-Olkin = 0.73 and the Bartlett's test of sphericity, χ²(253) = 755.791, p < 0.001 indicated that the raw data were suitable. Given the convergence of the Scree plot, Kaiser's criterion and dropping of cross loading items, a 16-item ECAST was produced with three sub scales: Appetite cue; Food responsiveness and Emotion and preference, which were internally valid and had good test-retest reliability (Cronbach's alpha 0.6 and test-retest reliability 0.797). Total ECAST scores of wasted children with good appetite were significantly higher from those with poor appetite (p = 0.004 and 0.001 for two wasted groups respectively). Results suggest that ECAST may provide a useful measure to assess the appetite level of under-five children.

Zinc Absorption from Micronutrient Powders Is Low in Bangladeshi Toddlers at Risk of Environmental Enteric Dysfunction and May Increase Dietary Zinc Requirements

Background

Environmental enteric dysfunction (EED), a chronic inflammatory disorder of the small bowel, is suspected to impair absorption of micronutrients, including zinc.

Objective

The objective of this study was to compare zinc absorption from micronutrient powder (MNP) over a range of zinc doses in young children screened for EED with use of the lactulose:mannitol ratio (L:M).

Methods

Bangladeshi children aged 18-24 mo, grouped according to high and low L:M (≥0.09 and <0.09, respectively), were randomly assigned to MNP with 0, 5, 10, or 15 mg Zn/sachet (10 subjects per dose per L:M group). Over a day, fractional absorption of zinc was measured from an MNP-fortified meal and from unfortified meals with stable isotope tracers; total daily absorbed zinc (TAZ, milligrams per day) was determined as the primary outcome. Secondary outcomes included investigation of relations of TAZ to intake, to physiologic requirement, and to other variables, including biomarkers of systemic and intestinal inflammation, using nonlinear models. TAZ was also compared with published data on child zinc absorption.

Results

In 74 subjects who completed the study, zinc absorption did not differ by L:M grouping. Most biomarkers of intestinal inflammation were elevated in both L:M groups. For combined L:M groups, mean ± SD TAZ for each MNP dose (0, 5, 10, and 15 mg/sachet) was 0.57 ± 0.30, 0.68 ± 0.31, 0.90 ± 0.43, and 1.0 ± 0.39 mg/d, respectively (P = 0.002), and exceeded the estimated physiologic requirement only for the 10- and 15-mg MNP doses. Zinc absorption was notably lower at all intake levels compared with published data (P < 0.0001) and was inversely related to serum α-1 acid glycoprotein and to fecal Entamoeba histolytica (P = 0.02).

Conclusion

Results indicate impaired absorption of zinc, which may predispose to zinc deficiency in young children with evidence of enteropathy. These findings suggest that current doses of zinc in MNP may be insufficient to yield zinc-related preventative benefits in similar settings. This study is registered at clinicaltrials.gov as NCT02758444.

Functional Prediction of Hypothetical Proteins from Shigella flexneri and Validation of the Predicted Models by Using ROC Curve Analysis

Shigella spp. constitutes some of the key pathogens responsible for the global burden of diarrhoeal disease. With over 164 million reported cases per annum, shigellosis accounts for 1.1 million deaths each year. Majority of these cases occur among the children of the developing nations and the emergence of multi-drug resistance Shigella strains in clinical isolates demands the development of better/new drugs against this pathogen. The genome of Shigella flexneri was extensively analyzed and found 4,362 proteins among which the functions of 674 proteins, termed as hypothetical proteins (HPs) had not been previously elucidated. Amino acid sequences of all these 674 HPs were studied and the functions of a total of 39 HPs have been assigned with high level of confidence. Here we have utilized a combination of the latest versions of databases to assign the precise function of HPs for which no experimental information is available. These HPs were found to belong to various classes of proteins such as enzymes, binding proteins, signal transducers, lipoprotein, transporters, virulence and other proteins. Evaluation of the performance of the various computational tools conducted using receiver operating characteristic curve analysis and a resoundingly high average accuracy of 93.6% were obtained. Our comprehensive analysis will help to gain greater understanding for the development of many novel potential therapeutic interventions to defeat Shigella infection.

Genetic Diversity of Noroviruses Circulating in a Pediatric Cohort in Bangladesh

Noroviruses are a leading cause of diarrhea in children aged <5 years worldwide. We genotyped 88 viruses collected by active surveillance in a birth cohort of children <2 years of age in Dhaka, Bangladesh, during 2010-2013. Twenty-five of 31 (81%) established GI and GII genotypes were detected, with GII.4 as the predominant genotype (20%). Our results show that children in Bangladesh are infected with a great diversity of norovirus strains. Reinfections are common, but not with closely related genotypes. Birth cohort studies are critical to understand cross-protective immunity and advance the development of pediatric norovirus vaccines.

Association of intestinal pathogens with faecal markers of environmental enteric dysfunction among slum-dwelling children in the first 2 years of life in Bangladesh

OBJECTIVE

Environmental Enteric Dysfunction (EED) can be assessed by faecal biomarkers such as Myeloperoxidase (MPO), Neopterin (NEO) and Alpha-1 anti-trypsin (AAT). We aimed to test the association of intestinal pathogens with faecal markers of EED among slum-dwelling children in first 2 years of life.

METHODS

The MAL-ED birth cohort data of Bangladesh site were used to conduct this analysis. Multivariable analyses using Generalized Estimating Equations (GEE) were performed to test the association between intestinal pathogens and faecal markers of EED.

RESULTS

Giardiasis, ascariasis and trichuriasis were the most frequent parasitic infections and Campylobacter spp., Enteroaggregative Escherichia coli (EAEC) and Enterotoxigenic Escherichia coli (ETEC) were the common bacterial pathogens observed in stool samples of the children. Overall, 71%, 97% and 58% of stool samples were above values considered normal in non-tropical settings for MPO, NEO and AAT respectively. Giardiasis was found to be significantly associated with MPO (Coefficient = 0.55; 95% CI = 0.15, 0.95; P-value = 0.008) and AAT concentrations (Coefficient = 0.34; 95% CI = 0.04, 0.63; P-value = 0.03). A significant association was found between trichuriasis and NEO (Coefficient = 0.90; 95% CI = 0.19, 1.61; P-value = 0.01). Trichuriasis (Coefficient = 1.71; 95% CI = 0.32, 3.11; P-value = 0.02) and giardiasis (Coefficient = 1.51; 95% CI = 0.79, 2.23; P-value <0.001) were significantly associated with EED score. Children with EAEC had significantly higher MPO concentrations (Coefficient = 0.33; 95% CI = 0.06, 0.61; P-value = 0.02).

CONCLUSION

The study results imply the importance of intestinal pathogens in contributing to intestinal inflammation and increased intestinal permeability in young children.

Association of Fecal Markers of Environmental Enteric Dysfunction with Zinc and Iron Status among Children at First Two Years of Life in Bangladesh

Environmental enteric dysfunction (EED) causes gut inflammation and increased intestinal permeability leading to deficiencies in micronutrients such as zinc and iron. Fecal markers such as myeloperoxidase (MPO), neopterin (NEO), and alpha-1-anti-trypsin (AAT) can predict EED. The aim of this study was to examine the association between fecal markers of EED with zinc and iron status among children at first 2 years of life. Malnutrition and Enteric Disease Study Bangladeshi birth cohort data were used to conduct this analysis. Multivariable analyses using generalized estimating equations were performed to test the association between individual fecal markers with zinc or iron status of the children. A total of 265 children were enrolled in the study (male:female = 1:1). Of the 627 stool samples collected (N = 222 children), 535, 511, and 577 were accompanied by zinc, ferritin, and soluble transferrin receptor values, respectively. Median (interquartile range [IQR]) values of AAT, MPO, and NEO were 0.33 (0.18-0.62) mg/g, 3,895.42 (1,563.76-8,432.82) ng/mL, and 890.81 (331.57-2,089.04) nmol/L, respectively. Overall, 60%, 71%, and 97% of samples were above the values considered normal in nontropical settings for AAT, MPO, and NEO, respectively. High AAT levels were significantly associated with low ferritin values after adjusting for age and gender (coefficient = -5.85; 95% confidence interval = -11.23 to -0.47; P value = 0.03). No such association was found between AAT and plasma zinc status. Myeloperoxidase and NEO were not associated with plasma zinc or iron status. The study results imply the importance of enteric protein loss in contributing to reduced ferritin levels at first 2 years of life.

Children living in the slums of Bangladesh face risks from unsafe food and water and stunted growth is common

AIM

This study investigated the microbial quality of food and water consumed by children in four slums in Dhaka, the capital of Bangladesh, together with the associated risk factors.

METHODS

This cross-sectional study took place from December 2015 to May 2016 and focused on 360 children under the age of five. We recorded household food security, namely adequate food for a healthy life, socio-economic and nutritional status, hygiene and feeding practices. Food and water samples were analysed.

RESULTS

We found that 63% of the children were malnourished and 58% were stunted. Yeast and moulds were detected in 86% of the food samples and coliforms in 73%. All the water samples were contaminated with faecal coliforms, yeasts and moulds and Staphylococcus. Food insecurity affected 83% of households. Children were twice as likely to be malnourished if they were born with a perceived low birthweight or their mothers did not wash their hands with soap after cleaning the child's bottom following defecation. Exclusively breastfed children were less likely to develop malnutrition.

CONCLUSION

Children from the Dhaka slums were frequently stunted and malnourished and contaminated food and water was common. Integrated efforts are essential to create public awareness about hygiene.

The management of persistent diarrhoea at Dhaka Hospital of the International Centre for Diarrhoeal Disease and Research: a clinical chart review

BACKGROUND

Persistent diarrhoea (PD) is poorly recognised and it requires proper assessment and early intervention to ensure effective treatment. The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) has been managing children with PD for more than two decades. This review focuses on different aspects of the management of PD in a hospital setting.

AIM

To estimate the prevalence, socio-demographic and clinical characteristics, treatment outcome and hospital course in under-5 children with persistent diarrhoea (PD).

METHODS

The hospital records of all children under 5 years admitted with PD to Dhaka Hospital of the International Centre for Diarrhoeal Disease Research between January 2012 and December 2013 were reviewed. Data were retrieved from the hospital's electronic database.

RESULTS

Of 8638 children under 5 years of age admitted with diarrhoea, 551 (6.4%) had PD and one-third had developed PD during their hospital stay. The incidence of PD was highest (228, 41.4%) in summer (April-June). Half (51%) of the children with PD had dehydration on admission. Fifty-seven (10.3%) had never been breastfed, 138 (25.1%) were severely wasted and 21 (3.8%) had bipedal oedema. Following the steps of a dietary algorithm, 224 (40.6%) patients responded to a milk-based low-lactose diet, 235 (42.6%) to a lactose-, sucrose- and milk-free diet, 48 (8.7%) to a comminuted chicken and glucose-based diet, 41 (7.4%) to exclusive breastfeeding, and 3 (0.5%) required a partially hydrolysed, semi-elemental diet. Major stool pathogens were Campylobacter species (23/59, 39%), Salmonella (10/59, 16.9%) and Shigella (10/59, 16.9%). The overall recovery rate from PD was 95.6% (527/551) and the duration of treatment until resolution of diarrhoea was 6 (3-9) days. The case-fatality rate was 2% (11/551).

CONCLUSION

Persistent diarrhoea remains an important public health problem in children under-5 in Bangladesh. Algorithm-based dietary management with simple clinical guidelines was effective in most cases. This treatment is appropriate in low-income settings where resources are limited.

Micronutrient adequacy is poor, but not associated with stunting between 12-24 months of age: A cohort study findings from a slum area of Bangladesh

The prevalence of stunting among children below 5 years of age is higher in the slum-dwelling population of Bangladesh compared to that in both urban and rural areas. Studies have reported that several factors such as inadequate nutrition, low socio-economic status, poor hygiene and sanitation and lack of maternal education are the substantial predictors of childhood stunting. Almost all these factors are universally present in the slum-dwelling population of Bangladesh. However, few studies have prospectively examined such determinants of stunting among slum populations. In this paper, we reveal the findings of a cohort study with an aim to explore the status of micronutrient adequacy among such vulnerable children and establish its association with stunting along with other determinants. Two-hundred-sixty-five children were enrolled and followed since birth until 24 months of age. We collected anthropometric, morbidity and dietary intake data monthly. We used the 24-hour multiple-pass recall approach to collect dietary intake data from the age of 9 months onward. Micronutrient adequacy of the diet was determined by the mean adequacy ratio (MAR) which was constructed from the average intake of 9 vitamins and 4 minerals considered for the analysis. We used generalized estimating equation (GEE) regression models to establish the determinants of stunting between 12–24 months of age in our study population. The prevalence of low-birth-weight (LBW) was about 28.7% and approximately half of the children were stunted by the age of 24 months. The average micronutrient intake was considerably lower than the recommended dietary allowance and the MAR was only 0.48 at 24 months of age compared to the optimum value of 1. However, the MAR was not associated with stunting between 12–24 months of age. Rather, LBW was the significant determinant (AOR = 3.03, 95% CI: 1.69–5.44) after adjusting for other factors such as age (AOR = 2.12, 95% CI: 1.45–3.11 at 24 months and AOR = 1.97, 95% CI: 1.49–2.59 at 18 months, ref: 12 months) and sex (AOR = 1.98, 95% CI: 1.17–3.33, ref: female). Improving the nutritional quality of complementary food in terms of adequacy of micronutrients is imperative for optimum growth but may not be adequate to mitigate under-nutrition in this setting. Further research should focus on identifying multiple strategies that can work synergistically to diminish the burden of stunting in resource-poor settings.

Risk factors of stunting among children living in an urban slum of Bangladesh: findings of a prospective cohort study

BACKGROUND

Bangladesh is one of the 20 countries with highest burden of stunting globally. A large portion (around 2.2 million) of the population dwells in the slum areas under severe vulnerable conditions. Children residing in the slums are disproportionately affected with higher burden of undernutrition particularly stunting. In this paper, findings of a prospective cohort study which is part of a larger multi-country study are presented.

METHODS

Two hundred and sixty five children were enrolled and followed since their birth till 24 months of age. Anthropometric measurements, dietary intake and morbidity information were collected monthly. Data from 9 to 12, 15-18 and 21-24 months were collated to analyze and report findings for 12, 18 and 24 months of age. Generalized estimating equation models were constructed to determine risk factors of stunting between 12 and 24 months of age.

RESULT

Approximately, 18% of children were already stunted (LAZ < -2SD) at birth and the proportion increased to 48% at 24 months of age. Exclusive breastfeeding prevalence was only 9.4% following the WHO definition at 6 months. Dietary energy intake as well as intakes of carbohydrate, fat and protein were suboptimal for majority of the children. However, in regression analysis, LAZ at birth (AOR = 0.40, 95% CI: 0.26, 0.61), household with poor asset index (AOR = 2.81, 95% CI: 1.43, 5.52; ref.: average asset index), being male children (AOR = 1.75, 95% CI: 1.04, 2.95; ref.: female) and age (AOR = 2.34, 95% CI: 1.56, 3.52 at 24 months, AOR = 2.13, 95% CI: 1.55, 2.92 at 18 months; ref.: 12 months of age) were the significant predictors of stunting among this population.

CONCLUSION

As the mechanism of stunting begins even before a child is born, strategies must be focused on life course approach and preventive measurement should be initiated during pregnancy. Alongside, government and policymakers have to develop sustainable strategies to improve various social and environmental factors those are closely interrelated with chronic undernutrition particularly concentrating on urban slum areas.

Relationships among Common Illness Symptoms and the Protective Effect of Breastfeeding in Early Childhood in MAL-ED: An Eight-Country Cohort Study

Children in low-income countries experience multiple illness symptoms in early childhood. Breastfeeding is protective against diarrhea and respiratory infections, and these illnesses are thought to be risk factors of one another, but these relationships have not been explored simultaneously. In the eight-site MAL-ED study, 1,731 infants were enrolled near birth and followed for 2 years. We collected symptoms and diet information through twice-weekly household visits. Poisson regression was used to determine if recent illness history was associated with incidence of diarrhea or acute lower respiratory infections (ALRI), accounting for exclusive breastfeeding. Recent diarrhea was associated with higher risk of incident diarrhea after the first 6 months of life (relative risk [RR] 1.10, 95% confidence interval [CI] 1.04, 1.16) and with higher risk of incident ALRI in the 3- to 5-month period (RR 1.23, 95% CI 1.03, 1.47). Fever was a consistent risk factor for both diarrhea and ALRI. Exclusive breastfeeding 0-6 months was protective against diarrhea (0-2 months: RR 0.39, 95% CI 0.32, 0.49; 3-5 months: RR 0.83, 95% CI 0.75, 0.93) and ALRI (3-5 months: RR 0.81, 95% CI 0.68, 0.98). Children with recent illness who were exclusively breastfed were half as likely as those not exclusively breastfed to experience diarrhea in the first 3 months of life. Recent illness was associated with greater risk of new illness, causing illnesses to cluster within children, indicating that specific illness-prevention programs may have benefits for preventing other childhood illnesses. The results also underscore the importance of exclusive breastfeeding in the first 6 months of life for disease prevention.

Early Antibiotic Exposure in Low-resource Settings Is Associated With Increased Weight in the First Two Years of Life

OBJECTIVES

The potential growth-promoting effects of antibiotics are not well understood among undernourished children in environments with high pathogen exposure. We aimed to assess whether early antibiotic exposure duration and class were associated with growth to 2 years of age across 8 low-resource sites in the MAL-ED birth cohort study.

METHODS

We followed 1954 children twice per week from birth to 2 years to record maternally reported antibiotic exposures and measure anthropometry monthly. We estimated the associations between antibiotic exposure before 6 months of age and weight-for-age and length-for-age (LAZ) z scores to 2 years. We assessed the impact of class-specific exposures and duration, and compared these results to effects of antibiotic exposures after 6 months of age.

RESULTS

Antibiotic use before 6 months of age was associated with increased weight from 6 months to 2 years, whereas associations with length were less consistent across sites and antibiotic classes. Compared to unexposed children, 2 or more courses of metronidazole, macrolides, and cephalosporins were associated with adjusted increases in weight-for-age of 0.24 (95% confidence interval (CI): 0.04, 0.43), 0.23 (95% CI: 0.05, 0.42), and 0.19 (95% CI: 0.04, 0.35) from 6 months to 2 years, respectively.

CONCLUSIONS

Antibiotic use in low-resource settings was most associated with the ponderal growth of children who had multiple exposures to antibiotics with broad spectrum and anaerobic activity in early infancy. Opportunities for rational and targeted antibiotic therapy in low resource settings may also promote short-term weight gain in children, although longer-term physical growth and metabolic impacts are unknown.

Bangladesh Environmental Enteric Dysfunction (BEED) study: protocol for a community-based intervention study to validate non-invasive biomarkers of environmental enteric dysfunction

INTRODUCTION

Environmental enteric dysfunction (EED) is a subacute inflammatory condition of the small intestinal mucosa with unclear aetiology that may account for more than 40% of all cases of stunting. Currently, there are no universally accepted protocols for the diagnosis, treatment and ultimately prevention of EED. The Bangladesh Environmental Enteric Dysfunction (BEED) study is designed to validate non-invasive biomarkers of EED with small intestinal biopsy, better understand disease pathogenesis and identify potential therapeutic targets for interventions designed to control EED and stunting.

METHODS AND ANALYSIS

The BEED study is a community-based intervention where participants are recruited from three cohorts: stunted children aged 12-18 months (length for age Z-score (LAZ) <-2), at risk of stunting children aged 12-18 months (LAZ <-1 to -2) and malnourished adults aged 18-45 years (body mass index <18.5 kg/m²). After screening, participants eligible for study provide faecal, urine and plasma specimens to quantify the levels of candidate EED biomarkers before and after receiving a nutritional intervention. Participants who fail to respond to nutritional therapy are considered as the candidates for upper gastrointestinal endoscopy with biopsy. Histopathological scoring for EED will be performed on biopsies obtained from several locations within the proximal small intestine. Candidate EED biomarkers will be correlated with nutritional status, the results of histochemical and immunohistochemical analyses of epithelial and lamina propria cell populations, plus assessments of microbial community structure.

ETHICS AND DISSEMINATION

Ethics approval was obtained in all participating institutes. Results of this study will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov ID: NCT02812615. Registered on 21 June 2016.

Epidemiology of enteroaggregative Escherichia coli infections and associated outcomes in the MAL-ED birth cohort

Background

Enteroaggregative E. coli (EAEC) have been associated with mildly inflammatory diarrhea in outbreaks and in travelers and have been increasingly recognized as enteric pathogens in young children with and without overt diarrhea. We examined the risk factors for EAEC infections and their associations with environmental enteropathy biomarkers and growth outcomes over the first two years of life in eight low-resource settings of the MAL-ED study.

Methods

EAEC infections were detected by PCR gene probes for aatA and aaiC virulence traits in 27,094 non-diarrheal surveillance stools and 7,692 diarrheal stools from 2,092 children in the MAL-ED birth cohort. We identified risk factors for EAEC and estimated the associations of EAEC with diarrhea, enteropathy biomarker concentrations, and both short-term (one to three months) and long-term (to two years of age) growth.

Results

Overall, 9,581 samples (27.5%) were positive for EAEC, and almost all children had at least one detection (94.8%) by two years of age. Exclusive breastfeeding, higher enrollment weight, and macrolide use within the preceding 15 days were protective. Although not associated with diarrhea, EAEC infections were weakly associated with biomarkers of intestinal inflammation and more strongly with reduced length at two years of age (LAZ difference associated with high frequency of EAEC detections: -0.30, 95% CI: -0.44, -0.16).

Conclusions

Asymptomatic EAEC infections were common early in life and were associated with linear growth shortfalls. Associations with intestinal inflammation were small in magnitude, but suggest a pathway for the growth impact. Increasing the duration of exclusive breastfeeding may help prevent these potentially inflammatory infections and reduce the long-term impact of early exposure to EAEC.

Enteroaggregative E. coli (EAEC) are pathogens that infect the intestine and can cause diarrhea. They are also commonly identified among young children in low-resource settings, who can carry the pathogen without symptomatic diarrhea. We examined the risk factors for EAEC infections and their associations with child health outcomes over the first two years of life in eight low-resource settings of the MAL-ED study. EAEC infections were detected using molecular methods in more than 30,000 stools collected from 2,092 children in the MAL-ED study. We identified risk factors for EAEC and estimated the associations of EAEC with diarrhea, markers of intestinal health, and child growth. Almost all children were infected with EAEC at least once by two years of age. Exclusive breastfeeding, higher enrollment weight, and recent macrolide antibiotic use were protective against these infections. Although not associated with diarrhea in these children, EAEC infections were associated with intestinal inflammation and reduced length at two years of age. EAEC may impact child development, even in the absence of diarrhea, by causing intestinal inflammation and impairing child growth.

"Those who care much, understand much." Maternal perceptions of children's appetite: Perspectives from urban and rural caregivers of diverse parenting experience in Bangladesh

Appetite in children is an important determinant of nutritional intake and growth. The information used by caregivers to understand children's appetite can help inform infant and young child feeding promotion and appetite assessment. We conducted a qualitative study to (a) explore maternal perceptions and responses to children's appetite and (b) to identify how these factors differ by type of caregiver, level of maternal experience, and urban versus rural context. We used purposive sampling to recruit mothers and alternate caregivers into 14 total focus group discussions (six to eight participants in each group; N = 95) in both urban and rural settings in Bangladesh. To understand children's appetite, caregivers monitor children's dietary patterns, emotional signs, and physical and verbal cues. Healthy appetite was observed by willingness to eat diverse foods, finish offered portions, and by acceptance of foods without excessive prompting. Child illness was cited for a cause of low appetite, which was manifested through fussiness, and avoiding commonly consumed foods. Mothers described a limited set of feeding practices (offering diverse foods, playing, and cheering children with videos) to encourage consumption when children lacked appetite. Mothers' stress related to work was noted as a barrier to identifying appetite cues. Urban mothers described a lower access to instrumental social support for child feeding but informational support than mothers in the rural setting. Understanding caregivers' perceptions of children's appetite may inform strategies to improve responsive feeding and tool development to assess changes in appetite as early indicators of change in health or nutrition status among high-risk children.

Treatment outcome of children with persistent Diarrhoea admitted to an Urban Hospital, Dhaka during 2012-2013

BACKGROUND

Despite availability of treatment guidelines, persistent diarrhoea (PD) has been a major contributor of diarrhoeal deaths in low and middle income countries. We evaluated the outcome of children under the age of 5 years who were treated for PD using management algorithm with locally available foods in a diarrhoeal disease hospital in Dhaka.

METHODS

We extracted retrospective data from electronic database for all the under-five children admitted for PD in the Longer Stay Ward and Intensive Care Unit of the Dhaka hospital at icddr,b between 2012 and 2013. Descriptive analysis was done to explore available baseline socio-demographic, nutritional, and co-morbid statuses, pathogens from stool isolates, duration of treatment, use of antibiotics, duration of hospital stay and treatment success rates. We sought to investigate above mentioned descriptive features in addition to associated factors with time to recover from PD using survival analysis with Cox proportional hazard model.

RESULTS

A total number of 426 children with a median age of 7.46 (inter-quartile range IQR; 5.39, 9.43) months were admitted for PD during the study period. Of these, 95% of children were recovered from PD and discharged from the hospital. The median duration of treatment response was 6 (IQR 4, 9) days. The case fatality rate was 1.17%. Multivariate analysis among the children of 6 months or less showed that the rate of recovery from PD was 57% lower in children with severe stunting compared to those without severe stunting (HR 0.43, 95% CI 0.22, 0.88, p < 0.05), 42% lower in children with severe wasting (HR 0.58, 95% CI 0.36, 0.95, p < 0.05), and 81% reduced in children who developed hospital acquired infection (HAI) compared to those without HAI (HR 0.19, 95% CI 0.06, 0.62, p < 0.05). Among the children who were more than 6 months old, age in months (HR 1.05, 95% CI 1.02, 1.09) and female gender (HR 1.41, 95% CI 1.09, 1.84) had better rates of recovery from PD (p < 0.05). Moreover, among children more than 6 months of age, HAI (HR 0.44, 95% CI 0.26, 0.75), and antibiotic use (HR 0.40, 95% CI 0.28, 0.56) were associated with impeded recovery rates from PD (p < 0.05).

CONCLUSION

The treatment guideline for persistent diarrhoea patients followed at icddr,b Dhaka hospital was found to be successful and can be used in other treatment facilities of Bangladesh and other developing countries where any treatment algorithm for PD is unavailable. More emphasis is required to be given for the prevention of hospital acquired infection that may help to limit the use of antibiotic in order to enhance the recovery rate from PD.

Contextual Factors for Stunting Among Children of Age 6 to 24 Months in an Under-Privileged Community of Dhaka, Bangladesh

OBJECTIVE

To determine factors associated with stunting among children aged 6 to 24 months in a slum of Dhaka, Bangladesh.

METHODS

We conducted this case control study during November 2009 to December 2012. Children were classified as case if length-for-age Z-score (LAZ) was <-2 and as control if LAZ was >-1 SD. The logistic regression model was used to find the factors associated with stunting.

RESULTS

The significant risk factors for stunting were: child's age >12 months, maternal undernutrition, mother's education <5 years, consumption of untreated drinking water and monthly family income <100 USD.

CONCLUSION

The findings of this study reiterated the role of maternal undernutrition and less education, consumption of untreated drinking water and poor family income as important associated factors of childhood stunting in resource-poor setting.

Efficacy of World Health Organization guideline in facility-based reduction of mortality in severely malnourished children from low and middle income countries: A systematic review and meta-analysis

AIM

Globally more than 19 million under-five children suffer from severe acute malnutrition (SAM). Data on efficacy of World Health Organization's (WHO's) guideline in reducing SAM mortality are limited. We aimed to assess the efficacy of WHO's facility-based guideline for the reduction of under-five SAM children mortality from low and middle income countries (LMICs).

METHODS

A systematic search of literature published in 1980-2015 was conducted using electronic databases. Additional articles were identified from the reference lists and grey literature. Studies from LMICs where SAM children (0-59 months) were managed in facilities according to WHO's guideline were included. Outcome was reduction in SAM mortality measured by case fatality rate (CFR). The review was reported following the Grading of Recommendations Assessment Development and Evaluation and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline and meta-analyses done using RevMan 5.3®.

RESULTS

This review identified nine studies, which demonstrated reductions in SAM mortality. CFR ranged from 8 to 16% where WHO guideline applied. High rates of poverty, malnutrition, severe co-morbid condition, lack of resources and differences in treatment practices played a key role in large CFR variation. Most death occurred within 48 h of admission in Asia, between 4 days and 4 weeks in Africa and in Latin America. CFR was reduced by 41% (odds ratio: 0.59; 95% confidence interval: 0.46-0.76) when WHO guideline were applied. A 45% reduction in CFR was achieved after excluding human immunodeficiency virus positive cases. Dietary management also differed among WHO and conventional management.

CONCLUSION

Children receiving SAM inpatient care as per WHO guideline have reduced CFR compared to conventional treatment.

Association between enteropathogens and malnutrition in children aged 6-23 mo in Bangladesh: a case-control study

Background: Early exposure to enteropathogens has been associated with malnutrition in children in low-resource settings. However, the contribution of individual enteropathogens remains poorly defined. Molecular diagnostics offer an increase in sensitivity for detecting enteropathogens but have not been comprehensively applied to studies of malnutrition.Objective: We sought to identify enteropathogens associated with malnutrition in Bangladesh.Design: Malnourished children [weight-for-age z score (WAZ) <-2] aged 6-23 mo in Dhaka, Bangladesh, and identified by active community surveillance were enrolled as cases, and normal-weight children (WAZ >-1) of the same age and from the same community were enrolled as controls. Stools were collected at enrollment and, for cases, after a 5-mo nutritional intervention. Enrollment and follow-up stools were tested by quantitative polymerase chain reaction for 32 enteropathogens with the use of a custom-developed TaqMan Array Card.Results: Enteropathogen testing was performed on 486 cases and 442 controls upon enrollment and 365 cases at follow-up. At enrollment, the detection of enteroaggregative Escherichia coli (OR: 1.39; 95% CI: 1.05, 1.83), Campylobacter spp. (OR: 1.46; 95% CI: 1.11, 1.91), heat-labile enterotoxin-producing E. coli (OR: 1.55; 95% CI: 1.04, 2.33), Shigella/enteroinvasive E. coli (OR: 1.65; 95% CI: 1.10, 2.46), norovirus genogroup I (OR: 1.66; 95% CI: 1.23, 2.25), and Giardia (OR: 1.73; 95% CI: 1.20, 2.49) were associated with malnourished cases, and the total burden of these pathogens remained associated with malnutrition after adjusting for sociodemographic factors. The number of these pathogens at follow-up was negatively associated with the change in WAZ during the intervention (-0.10 change in WAZ per pathogen detected; 95% CI: -0.14, -0.06), whereas the number at enrollment was positively associated with the change in WAZ (0.05 change in WAZ per pathogen detected; 95% CI: 0.00, 0.10).Conclusions: A subset of enteropathogens was associated with malnutrition in this setting. Broad interventions designed to reduce the burden of infection with these pathogens are needed. This trial was registered at clinicaltrials.gov as NCT02441426.

Results with Complementary Food Using Local Food Ingredients

Appropriate complementary food is a must for optimum growth of infants and children. The food should be diverse and be given in sufficient quantities 2-4 times a day depending upon age. Poverty, food insecurity, and lack of awareness regarding the choice of nutritious food ingredients are deterrents to optimum complementary feeding. In Bangladesh, 77% of children do not receive appropriate complementary food and, hence, the high prevalence of childhood malnutrition. We developed ready-to-use complementary foods (RUCFs) using locally available food ingredients, rice/lentil and chickpea, which conform to standard specifications. These foods were found to be acceptable by children and their mothers compared to the Pushti packet, the cereal-based supplement used in the erstwhile National Nutrition Program of Bangladesh. In a cluster-randomized community-based trial in rural Bangladesh among more than 5,000 children, the efficacy of rice/lentil- and chickpea-based RUCFs was compared with another commonly used supplementary food called wheat-soy blend++ (WSB++) and a commercial product called Plumpy'doz. Deceleration in length for age was significantly lower (by 0.02-0.04/month) in the rice/lentil, Plumpy'doz, and chickpea groups compared to the control group at 18 months of age. Weight-for-length z-score decline was lower only in Plumpy'doz and chickpea groups. WSB++ was not different from the control group. In children who received chickpea RUCF or Plumpy'doz, the prevalence of stunting was 5-6% lower at 18 months. These foods can be used to prevent or treat malnutrition among children, particularly those from food-insecure households.

Vaccine coverage and adherence to EPI schedules in eight resource poor settings in the MAL-ED cohort study

BACKGROUND

Launched in 1974, the Expanded Program on Immunization (EPI) is estimated to prevent two-three million deaths annually from polio, diphtheria, tuberculosis, pertussis, measles, and tetanus. Additional lives could be saved through better understanding what influences adherence to the EPI schedule in specific settings.

METHODS

The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study followed cohorts in eight sites in South Asia, Africa, and South America and monitored vaccine receipt over the first two years of life for the children enrolled in the study. Vaccination histories were obtained monthly from vaccination cards, local clinic records and/or caregiver reports. Vaccination histories were compared against the prescribed EPI schedules for each country, and coverage rates were examined in relation to the timing of vaccination. The influence of socioeconomic factors on vaccine timing and coverage was also considered.

RESULTS

Coverage rates for EPI vaccines varied between sites and by type of vaccine; overall, coverage was highest in the Nepal and Bangladesh sites and lowest in the Tanzania and Brazil sites. Bacillus Calmette-Guérin coverage was high across all sites, 87-100%, whereas measles vaccination rates ranged widely, 73-100%. Significant delays between the scheduled administration age and actual vaccination date were present in all sites, especially for measles vaccine where less than 40% were administered on schedule. A range of socioeconomic factors were significantly associated with vaccination status in study children but these results were largely site-specific.

CONCLUSIONS

Our findings highlight the need to improve measles vaccination rates and reduce delayed vaccination to achieve EPI targets related to the establishment of herd immunity and reduction in disease transmission.

Undernutrition, Vitamin A and Iron Deficiency Are Associated with Impaired Intestinal Mucosal Permeability in Young Bangladeshi Children Assessed by Lactulose/Mannitol Test

BACKGROUND

Lactulose/mannitol (L:M) test has been used as a non-invasive marker of intestinal mucosal -integrity and -permeability (enteropathy). We investigated the association of enteropathy with anthropometrics, micronutrient- status, and morbidity in children.

METHODS

The urine and blood samples were collected from 925 children aged 6-24 months residing in Mirpur slum of Dhaka, Bangladesh during November 2009 to April 2013. L:M test and micronutrient status were assessed in the laboratory of International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b) following standard procedure.

RESULTS

Mean±SD age of the children was 13.2±5.2 months and 47.8% were female. Urinary- lactulose recovery was 0.264±0.236, mannitol recovery was 3.423±3.952, and L:M was 0.109±0.158. An overall negative correlation (Spearman's-rho) of L:M was found with age (rs = -0.087; p = 0.004), weight-for-age (rs = -0.077; p = 0.010), weight-for-length (rs = -0.060; p = 0.034), mid-upper-arm-circumference (rs = -0.098; p = 0.001) and plasma-retinol (rs = -0.105; p = 0.002); and a positive correlation with plasma α-1-acid glycoprotein (rs = 0.066; p = 0.027). However, most of the correlations were not very strong. Approximately 44% of children had enteropathy as reflected by L:M of ≥0.09. Logistic regression analysis revealed that younger age (infancy) (adjusted odds ratio (AOR) = 1.35; p = 0.027), diarrhea (AOR = 4.00; p = 0.039) or fever (AOR = 2.18; p = 0.003) within previous three days of L:M test were the risk factors of enteropathy (L:M of ≥0.09).

CONCLUSIONS

Enteropathy (high L:M) is associated with younger age, undernutrition, low vitamin A and iron status, and infection particularly diarrhea and fever.