1
|
Leili M, Afrasiabi S, Rostami R, Khazaei M, Roshani M, Tarin Z. The evaluation of Staphylococcus aureus and Staphylococcus epidermidis in hospital air, their antibiotic resistance and sensitivity of S. aureus to cefoxitin. Sci Rep 2024; 14:9183. [PMID: 38649676 PMCID: PMC11035647 DOI: 10.1038/s41598-024-59463-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 04/10/2024] [Indexed: 04/25/2024] Open
Abstract
Staphylococci as a nosocomial infection agent, increases the possibility of contracting diseases such as wound infection, sepsis and skin infections in humans. It was shown that Staphylococcus aureus considered as a commensal organism causing various both endemic and epidemic hospital-acquired infections. Air samples were collected from Sina Hospital, Hamadan city, which dedicated to various respiratory diseases and analysed by biochemical tests. The resistance and sensitivity of bacterial strains to the cefoxitin antibiotic were also determined. Staphylococcus aureus density (CFU/m3) were measured in the air of various wards as follows: infectious 13.35 ± 7.57, poisoning 29.84 ± 33.43, emergency 8.64 ± 2.72, eye operation room 0, recovery room 6.28 ± 4.90, skin outpatient operation room 4.71 ± 2.36, respiratory isolation 0, ICU 0.79 ± 1.36, and the administrative room 6.28 ± 5.93; while the Staphylococcus epidermidis were as follows: infectious 1.57 ± 2.35, poisoning 2.35 ± 4.08, emergency 2.35 ± 2.35, eye operation room 0, recovery room 0.78 ± 1.36, skin outpatient operation room 2.35 ± 2.35, respiratory isolation 0, ICU 2.35 ± 4.08, and the administrative room 1.57 ± 1.36. The positive and negative control samples showed a concentration of 0. Moreover, among the S. aureus isolates, 33.3% were found to be resistant to cefoxitin, while 40.6% showed to be sensitive. Based on the results, the number of active people and the type and quality of ventilation are very effective in the air quality of various wards of hospital. The poisoning section showed the most contaminated air and the highest resistance and sensitivity to the cefoxitin antibiotic.
Collapse
Affiliation(s)
- Mostafa Leili
- Department of Environmental Health Engineering, School of Public Health and Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Sedighe Afrasiabi
- Department of Environmental Health Engineering, School of Public Health, Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Roohollah Rostami
- Department of Environmental Health Engineering, Research Center for Health Sciences and Technologies, Semnan University of Medical Sciences, Semnan, Iran
| | - Mohammad Khazaei
- Department of Environmental Health Engineering, School of Public Health and Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mahdaneh Roshani
- Department of Microbiology, Faculty of Medicine, Medical Microbiology, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Zahra Tarin
- Department of Occupational Health Engineering, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| |
Collapse
|
2
|
Chauvet L, Ménard O, Le Gouar Y, Henry G, Jardin J, Hennetier M, Croguennec T, Van Audenhaege M, Dupont D, Lemaire M, Le Huërou-Luron I, Deglaire A. Protein ingredient quality of infant formulas impacts their structure and kinetics of proteolysis under in vitro dynamic digestion. Food Res Int 2023; 169:112883. [PMID: 37254331 DOI: 10.1016/j.foodres.2023.112883] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 06/01/2023]
Abstract
Infant formula (IF) is a complex matrix requiring numerous ingredients and processing steps. The objective was to understand how the quality of protein ingredients impacts IF structure and, in turn, their kinetics of digestion. Four powdered IFs (A/B/C/D), based on commercial whey protein (WP) ingredients, with different protein denaturation levels and composition (A/B/C), and on caseins with different supramolecular organisations (C/D), were produced at a semi-industrial level after homogenization and spray-drying. Once reconstituted in water (13 %, wt/wt), the IF microstructure was analysed with asymmetrical flow field-flow fractionation coupled with multi-angle light scattering and differential refractometer, transmission electron microscopy and electrophoresis. The rehydrated IFs were subjected to simulated infant in vitro dynamic digestion (DIDGI®). Digesta were regularly sampled to follow structural changes (confocal microscopy, laser-light scattering) and proteolysis (OPA, SDS-PAGE, LC-MS/MS, cation-exchange chromatography). Before digestion, different microstructures were observed among IFs. IF-A, characterized by more denatured WPs, presented star-shaped mixed aggregates, with protein aggregates bounded to casein micelles, themselves adsorbed at the fat droplet interface. Non-micellar caseins, brought by non-micellar casein powder (IF-D) underwent rearrangement and aggregation at the interface of flocculated fat droplets, leading to a largely different microstructure of IF emulsion, with large aggregates of lipids and proteins. During digestion, IF-A more digested (degree of proteolysis + 16 %) at 180 min of intestinal phase than IF-C/D. The modification of the supramolecular organisation of caseins implied different kinetics of peptide release derived from caseins during the gastric phase (more abundant at G80 for IF-D). Bioactive peptide release kinetics were also different during digestion with IF-C presenting a maximal abundance for a large proportion of them. Overall, the present study highlights the importance of the structure and composition of the protein ingredients (WPs and caseins) selected for IF formulation on the final IF structure and, in turn, on proteolysis. Whether it has some physiological consequences remains to be investigated.
Collapse
Affiliation(s)
- Lucile Chauvet
- INRAE, Institut Agro, STLO, 35042 Rennes, France; Institut NuMeCan, INRAE, INSERM, Univ Rennes, Saint Gilles, France; SODIAAL International, Centre Recherche & Innovation, Rennes, France
| | | | | | | | | | - Marie Hennetier
- Université de Toulouse, Institut National Polytechnique de Toulouse - Ecole d'ingénieur de Purpan, Département Sciences Agronomique et Agroalimentaire, Toulouse, France
| | | | | | | | - Marion Lemaire
- SODIAAL International, Centre Recherche & Innovation, Rennes, France
| | | | | |
Collapse
|
3
|
Charton E, Bourgeois A, Bellanger A, Le-Gouar Y, Dahirel P, Romé V, Randuineau G, Cahu A, Moughan PJ, Montoya CA, Blat S, Dupont D, Deglaire A, Le Huërou-Luron I. Infant nutrition affects the microbiota-gut-brain axis: Comparison of human milk vs. infant formula feeding in the piglet model. Front Nutr 2022; 9:976042. [PMID: 36211510 PMCID: PMC9532976 DOI: 10.3389/fnut.2022.976042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
Early nutrition plays a dominant role in infant development and health. It is now understood that the infant diet impacts the gut microbiota and its relationship with gut function and brain development. However, its impact on the microbiota-gut-brain axis has not been studied in an integrative way. The objective here was to evaluate the effects of human milk (HM) or cow’s milk based infant formula (IF) on the relationships between gut microbiota and the collective host intestinal-brain axis. Eighteen 10-day-old Yucatan mini-piglets were fed with HM or IF. Intestinal and fecal microbiota composition, intestinal phenotypic parameters, and the expression of genes involved in several gut and brain functions were determined. Unidimensional analyses were performed, followed by multifactorial analyses to evaluate the relationships among all the variables across the microbiota-gut-brain axis. Compared to IF, HM decreased the α-diversity of colonic and fecal microbiota and modified their composition. Piglets fed HM had a significantly higher ileal and colonic paracellular permeability assessed by ex vivo analysis, a lower expression of genes encoding tight junction proteins, and a higher expression of genes encoding pro-inflammatory and anti-inflammatory immune activity. In addition, the expression of genes involved in endocrine function, tryptophan metabolism and nutrient transport was modified mostly in the colon. These diet-induced intestinal modifications were associated with changes in the brain tissue expression of genes encoding the blood-brain barrier, endocrine function and short chain fatty acid receptors, mostly in hypothalamic and striatal areas. The integrative approach underlined specific groups of bacteria (Veillonellaceae, Enterobacteriaceae, Lachnospiraceae, Rikenellaceae, and Prevotellaceae) associated with changes in the gut-brain axis. There is a clear influence of the infant diet, even over a short dietary intervention period, on establishment of the microbiota-gut-brain axis.
Collapse
Affiliation(s)
- Elise Charton
- STLO, INRAE, Institut Agro, Rennes, France
- Institut NuMeCan, INRAE, INSERM, Univ Rennes, Saint-Gilles, France
| | | | | | | | - Patrice Dahirel
- Institut NuMeCan, INRAE, INSERM, Univ Rennes, Saint-Gilles, France
| | - Véronique Romé
- Institut NuMeCan, INRAE, INSERM, Univ Rennes, Saint-Gilles, France
| | | | - Armelle Cahu
- Institut NuMeCan, INRAE, INSERM, Univ Rennes, Saint-Gilles, France
| | - Paul J. Moughan
- Riddet Institute, Massey University, Palmerston North, New Zealand
| | - Carlos A. Montoya
- Riddet Institute, Massey University, Palmerston North, New Zealand
- Smart Foods and Bioproducts Innovation Centre of Excellence, AgResearch Limited, Palmerston North, New Zealand
| | - Sophie Blat
- Institut NuMeCan, INRAE, INSERM, Univ Rennes, Saint-Gilles, France
| | | | | | - Isabelle Le Huërou-Luron
- Institut NuMeCan, INRAE, INSERM, Univ Rennes, Saint-Gilles, France
- *Correspondence: Isabelle Le Huërou-Luron,
| |
Collapse
|
4
|
Intestinal Barrier Permeability in Obese Individuals with or without Metabolic Syndrome: A Systematic Review. Nutrients 2022; 14:nu14173649. [PMID: 36079905 PMCID: PMC9459697 DOI: 10.3390/nu14173649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 12/13/2022] Open
Abstract
Altered intestinal barrier permeability has been associated with obesity and its metabolic and inflammatory complications in animal models. The purpose of this systematic review is to assess the evidence regarding the association between obesity with or without Metabolic Syndrome (MetS) and alteration of the intestinal barrier permeability in humans. A systematic search of the studies published up until April 2022 in Latin America & Caribbean Health Sciences Literature (LILACS), PubMed, Scopus, Embase, and ScienceDirect databases was conducted. The methodological quality of the studies was assessed using the Newcastle–Ottawa scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) checklist. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the quality of the evidence. Eight studies were included and classified as moderate to high quality. Alteration of intestinal barrier permeability was evaluated by zonulin, lactulose/mannitol, sucralose, sucrose, lactulose/L-rhamnose, and sucralose/erythritol. Impaired intestinal barrier permeability measured by serum and plasma zonulin concentration was positively associated with obesity with MetS. Nonetheless, the GRADE assessment indicated a very low to low level of evidence for the outcomes. Thus, clear evidence about the relationship between alteration of human intestinal barrier permeability, obesity, and MetS was not found.
Collapse
|
5
|
Crane RJ, Parker EP, Fleming S, Gwela A, Gumbi W, Ngoi JM, de Laurent ZR, Nyatichi E, Ngari M, Wambua J, Uhlig HH, Berkley JA. Cessation of exclusive breastfeeding and seasonality, but not small intestinal bacterial overgrowth, are associated with environmental enteric dysfunction: A birth cohort study amongst infants in rural Kenya. EClinicalMedicine 2022; 47:101403. [PMID: 35497062 PMCID: PMC9046123 DOI: 10.1016/j.eclinm.2022.101403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 12/18/2022] Open
Abstract
Background Environmental Enteric Dysfunction (EED) is a chronic intestinal inflammatory disorder of unclear aetiology prevalent amongst children in low-income settings and associated with stunting. We aimed to characterise development of EED and its putative risk factors amongst rural Kenyan infants. Methods In a birth cohort study in Junju, rural coastal Kenya, between August 2015 and January 2017, 100 infants were each followed for nine months. Breastfeeding status was recorded weekly and anthropometry monthly. Acute illnesses and antibiotics were captured by active and passive surveillance. Intestinal function and small intestinal bacterial overgrowth (SIBO) were assessed by monthly urinary lactulose mannitol (LM) and breath hydrogen tests. Faecal alpha-1-antitrypsin, myeloperoxidase and neopterin were measured as EED biomarkers, and microbiota composition assessed by 16S sequencing. Findings Twenty nine of the 88 participants (33%) that underwent length measurement at nine months of age were stunted (length-for-age Z score <-2). During the rainy season, linear growth was slower and LM ratio was higher. In multivariable models, LM ratio, myeloperoxidase and neopterin increased after cessation of continuous-since-birth exclusive breastfeeding. For LM ratio this only occurred during the rainy season. EED markers were not associated with antibiotics, acute illnesses, SIBO, or gut microbiota diversity. Microbiota diversified with age and was not strongly associated with complementary food introduction or linear growth impairment. Interpretation Our data suggest that intensified promotion of uninterrupted exclusive breastfeeding amongst infants under six months during the rainy season, where rainfall is seasonal, may help prevent EED. Our findings also suggest that therapeutic strategies directed towards SIBO are unlikely to impact on EED in this setting. However, further development of non-invasive diagnostic methods for SIBO is required. Funding This research was funded in part by the Wellcome Trust (Research Training Fellowship to RJC (103376/Z/13/Z)). EPKP was supported by the MRC/DfID Newton Fund (MR/N006259/1). JAB was supported by the MRC/DFiD/Wellcome Trust Joint Global Health Trials scheme (MR/M007367/1) and the Bill & Melinda Gates Foundation (OPP1131320). HHU was supported by the NIHR Oxford Biomedical Research Centre (IS-BRC-1215-20008).
Collapse
Affiliation(s)
- Rosie J. Crane
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LG, UK
- KEMRI Wellcome Trust Research Programme, PO Box 80108-230, Kilifi, Kenya
| | - Edward P.K. Parker
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Simon Fleming
- Royal Cornwall Hospitals NHS Trust, Treliske, Truro TR1 3LQ, UK
| | - Agnes Gwela
- KEMRI Wellcome Trust Research Programme, PO Box 80108-230, Kilifi, Kenya
| | - Wilson Gumbi
- KEMRI Wellcome Trust Research Programme, PO Box 80108-230, Kilifi, Kenya
| | - Joyce M. Ngoi
- KEMRI Wellcome Trust Research Programme, PO Box 80108-230, Kilifi, Kenya
- West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, PO Box LG54, Accra, Ghana
| | | | - Emily Nyatichi
- KEMRI Wellcome Trust Research Programme, PO Box 80108-230, Kilifi, Kenya
| | - Moses Ngari
- KEMRI Wellcome Trust Research Programme, PO Box 80108-230, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition (CHAIN) Network, P.O Box 43640 – 00100, Nairobi, Kenya
| | - Juliana Wambua
- KEMRI Wellcome Trust Research Programme, PO Box 80108-230, Kilifi, Kenya
| | - Holm H. Uhlig
- Translational Gastroenterology Unit, University of Oxford, Oxford OX3 9DU, UK
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 9DU, UK
| | - James A. Berkley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LG, UK
- KEMRI Wellcome Trust Research Programme, PO Box 80108-230, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition (CHAIN) Network, P.O Box 43640 – 00100, Nairobi, Kenya
| |
Collapse
|
6
|
Enteropathogen spectrum and effect on antimycobacterial pharmacokinetics among children with tuberculosis in rural Tanzania: a prospective cohort study. THE LANCET MICROBE 2022; 3:e408-e416. [PMID: 35659902 PMCID: PMC9174596 DOI: 10.1016/s2666-5247(21)00308-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 02/03/2023] Open
|
7
|
Kortekangas E, Fan YM, Chaima D, Lehto KM, Malamba-Banda C, Matchado A, Chingwanda C, Liu Z, Ashorn U, Cheung YB, Dewey KG, Maleta K, Ashorn P. Associations between Gut Microbiota and Intestinal Inflammation, Permeability and Damage in Young Malawian Children. J Trop Pediatr 2022; 68:6527323. [PMID: 35149871 PMCID: PMC8846364 DOI: 10.1093/tropej/fmac012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Environmental enteric dysfunction (EED) is common in low- and middle-income countries and associated with childhood undernutrition. The composition of gut microbiota has been implicated in the pathogenesis of EED. Our aim was to assess the associations between gut microbiota and EED biomarkers in rural Malawian children. We hypothesized that there would be an inverse association between microbiota maturity and diversity and fecal concentrations of EED biomarkers. METHODS We used data from fecal samples collected at 6, 18 and 30 months from 611 children who were followed up during a nutrition intervention trial. The primary time point for analysis was 18 months. Microbiota data were obtained through 16S rRNA sequencing and variables included microbiota maturity and diversity, phylogenetic dissimilarity and relative abundances of individual taxa. EED biomarkers included calprotectin (marker of inflammation), alpha-1 antitrypsin (intestinal permeability) and REG1B (intestinal damage). RESULTS There was an inverse association between microbiota maturity and diversity and fecal concentrations of all 3 EED biomarkers at 18 months (p≤0.001). The results were similar at 30 months, while at 6 months inverse associations were found only with calprotectin and alpha-1 antitrypsin concentrations. At 18 months, EED biomarkers were not associated with phylogenetic dissimilarity, but at 6 and 30 months several associations were observed. Individual taxa predicting EED biomarker concentrations at 18 months included several Bifidobacterium and Enterobacteriaceae taxa as well as potentially displaced oral taxa. CONCLUSIONS Our findings support the hypothesis of an inverse association between microbiota maturity and diversity and EED in rural Malawian children.
Collapse
Affiliation(s)
- Emma Kortekangas
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland,Correspondence: Emma Kortekangas, Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Global Health, Tampere University, Arvo Ylpön katu 34, Arvo building, Tampere 33014, Finland. Tel: +358-3-355-111. Fax +358-3-213-4473. E-mail <>
| | - Yue-Mei Fan
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland
| | - David Chaima
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kirsi-Maarit Lehto
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland
| | - Chikondi Malamba-Banda
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Andrew Matchado
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi,Department of Nutrition and Institute for Global Nutrition, University of California Davis, Davis, CA 95616, USA
| | - Chilungamo Chingwanda
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Zhifei Liu
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland
| | - Ulla Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland
| | - Yin Bun Cheung
- Program in Health Services & Systems Research and Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Kathryn G Dewey
- Department of Nutrition and Institute for Global Nutrition, University of California Davis, Davis, CA 95616, USA
| | - Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere 33014, Finland,Department of Pediatrics, Tampere University Hospital, Tampere 33520, Finland
| |
Collapse
|
8
|
Colston JM, Taniuchi M, Ahmed T, Ferdousi T, Kabir F, Mduma E, Nshama R, Iqbal NT, Haque R, Ahmed T, Ali Bhutta Z, Kosek MN, Platts-Mills JA. Intestinal Colonization With Bifidobacterium longum Subspecies Is Associated With Length at Birth, Exclusive Breastfeeding, and Decreased Risk of Enteric Virus Infections, but Not With Histo-Blood Group Antigens, Oral Vaccine Response or Later Growth in Three Birth Cohorts. Front Pediatr 2022; 10:804798. [PMID: 35252058 PMCID: PMC8888871 DOI: 10.3389/fped.2022.804798] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/13/2022] [Indexed: 11/30/2022] Open
Abstract
Bifidobacterium longum subspecies detected in infant stool have been associated with numerous subsequent health outcomes and are potential early markers of deviation from healthy developmental trajectories. This analysis derived indicators of carriage and early colonization with B. infantis and B. longum and quantified their associations with a panel of early-life exposures and outcomes. In a sub-study nested within a multi-site birth cohort, extant stool samples from infants in Bangladesh, Pakistan and Tanzania were tested for presence and quantity of two Bifidobacterium longum subspecies. The results were matched to indicators of nutritional status, enteropathogen infection, histo-blood group antigens, vaccine response and feeding status and regression models were fitted to test for associations while adjusting for covariates. B. infantis was associated with lower quantity of and decreased odds of colonization with B. longum, and vice versa. Length at birth was associated with a 0.36 increase in log10 B. infantis and a 0.28 decrease in B. longum quantity at 1 month of age. B. infantis colonization was associated with fewer viral infections and small reductions in the risk of rotavirus and sapovirus infections, but not reduced overall diarrheal disease risk. No associations with vaccine responses, HBGAs or later nutritional status were identified. Suboptimal intrauterine growth and a shorter duration of exclusive breastfeeding may predispose infants to early intestinal colonization with the B. longum subspecies at the expense of B. infantis, thus denying them potential benefits of reduced enteric virus episodes.
Collapse
Affiliation(s)
- Josh M Colston
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States
| | - Mami Taniuchi
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States
| | - Tahmina Ahmed
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States
| | - Tania Ferdousi
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Furqan Kabir
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom, Tanzania
| | | | - Najeeha Talat Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Zulfiqar Ali Bhutta
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Margaret N Kosek
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States.,Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States
| |
Collapse
|
9
|
Gene expression profiles compared in environmental and malnutrition enteropathy in Zambian children and adults. EBioMedicine 2021; 70:103509. [PMID: 34333236 PMCID: PMC8346547 DOI: 10.1016/j.ebiom.2021.103509] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/11/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Environmental enteropathy (EE) contributes to growth failure in millions of children worldwide, but its relationship to clinical malnutrition has not been elucidated. We used RNA sequencing to compare duodenal biopsies from adults and children with EE, and from children with severe acute malnutrition (SAM), to define key features of these malnutrition-related enteropathies. METHODS RNA was extracted and sequenced from biopsies of children with SAM in hospital (n=27), children with non-responsive stunting in the community (n=30), and adults living in the same community (n=37) using an identical sequencing and analysis pipeline. Two biopsies each were profiled and differentially expressed genes (DEGs) were computed from the comparisons of the three groups. DEG lists from these comparisons were then subjected to analysis with CompBio software to assemble a holistic view of the biological landscape and IPA software to interrogate canonical pathways. FINDINGS Dysregulation was identified in goblet cell/mucin production and xenobiotic metabolism/detoxification for both cohorts of children, versus adults. Within the SAM cohort, substantially greater induction of immune response and barrier function, including NADPH oxidases was noted, concordant with broadly reduced expression of genes associated with the brush border and intestinal structure/transport/absorption. Interestingly, down regulation of genes associated with the hypothalamic-pituitary-adrenal axis was selectively observed within the cohort of children with stunting. INTERPRETATION Gene expression profiles in environmental enteropathy and severe acute malnutrition have similarities, but SAM has several distinct transcriptional features. The intestinal capacity to metabolise drugs and toxins in malnourished children requires further study. FUNDING Bill & Melinda Gates Foundation (OPP1066118).
Collapse
|
10
|
Jamil Z, Iqbal NT, Idress R, Ahmed Z, Sadiq K, Mallawaarachchi I, Iqbal J, Syed S, Hotwani A, Kabir F, Ahmed K, Ahmed S, Umrani F, Ma JZ, Aziz F, Kalam A, Moore SR, Ali SA. Gut integrity and duodenal enteropathogen burden in undernourished children with environmental enteric dysfunction. PLoS Negl Trop Dis 2021; 15:e0009584. [PMID: 34264936 PMCID: PMC8352064 DOI: 10.1371/journal.pntd.0009584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 08/09/2021] [Accepted: 06/17/2021] [Indexed: 11/18/2022] Open
Abstract
Environmental enteric dysfunction (EED) is a subclinical condition of intestinal inflammation, barrier dysfunction and malabsorption associated with growth faltering in children living in poverty. This study explores association of altered duodenal permeability (lactulose, rhamnose and their ratio) with higher burden of enteropathogen in the duodenal aspirate, altered histopathological findings and higher morbidity (diarrhea) that is collectively associated with linear growth faltering in children living in EED endemic setting. In a longitudinal birth cohort, 51 controls (WHZ > 0, HAZ > −1.0) and 63 cases (WHZ< -2.0, refractory to nutritional intervention) were recruited. Anthropometry and morbidity were recorded on monthly bases up to 24 months of age. Dual sugar assay of urine collected after oral administration of lactulose and rhamnose was assessed in 96 children from both the groups. Duodenal histopathology (n = 63) and enteropathogen analysis of aspirate via Taqman array card (n = 60) was assessed in only cases. Giardia was the most frequent pathogen and was associated with raised L:R ratio (p = 0.068). Gastric microscopy was more sensitive than duodenal aspirate in H. pylori detection. Microscopically confirmed H. pylori negatively correlated with HAZ at 24 months (r = −0.313, p = 0.013). Regarding histopathological parameters, goblet cell reduction significantly correlated with decline in dual sugar excretion (p< 0.05). Between cases and controls, there were no significant differences in the median (25th, 75th percentile) of urinary concentrations (μg/ml) of lactulose [27.0 (11.50, 59.50) for cases vs. 38.0 (12.0, 61.0) for controls], rhamnose [66.0 (28.0, 178.0) vs. 86.5 (29.5, 190.5)] and L:R ratio [0.47 (0.24, 0.90) vs. 0.51 (0.31, 0.71)] respectively. In multivariable regression model, 31% of variability in HAZ at 24 months of age among cases and controls was explained by final model including dual sugars. In conclusion, enteropathogen burden is associated with altered histopathological features and intestinal permeability. In cases and controls living in settings of endemic enteropathy, intestinal permeability test may predict linear growth. However, for adoption as a screening tool for EED, further validation is required due to its complex intestinal pathophysiology. EED is a subclinical condition of compromised gut integrity secondary to frequent and repeated exposure to enteropathogens in global settings with a high prevalence of undernutrition. In this study, we reported association of gut mucosal architecture with a dual sugar intestinal permeability assay (lactulose-rhamnose) in Pakistani children. In the presence of duodenal enteropathogens, features such as chronic inflammation, intra-epithelial lymphocytosis, enterocyte injury and Paneth cell reduction were consistently observed. When comparing undernourished cases and controls living in the same setting, we found urinary excretion of the sugars was similar among groups; however, variability in HAZ among children at 24 months was partially explained by a model that includes excretion values.
Collapse
Affiliation(s)
- Zehra Jamil
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha Talat Iqbal
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Romana Idress
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Zubair Ahmed
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Indika Mallawaarachchi
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, United States of America
| | - Junaid Iqbal
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sana Syed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition; Department of Pediatrics, University of Virginia, Charlottesville, Virginia, United States of America
| | - Aneeta Hotwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Furqan Kabir
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kumail Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sheraz Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fayaz Umrani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jennie Z. Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, United States of America
| | - Fatima Aziz
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Adil Kalam
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sean R. Moore
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition; Department of Pediatrics, University of Virginia, Charlottesville, Virginia, United States of America
- * E-mail: (SRM); (SAA)
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- * E-mail: (SRM); (SAA)
| |
Collapse
|
11
|
Thompson AJ, Bourke CD, Robertson RC, Shivakumar N, Edwards CA, Preston T, Holmes E, Kelly P, Frost G, Morrison DJ. Understanding the role of the gut in undernutrition: what can technology tell us? Gut 2021; 70:gutjnl-2020-323609. [PMID: 34103403 PMCID: PMC8292602 DOI: 10.1136/gutjnl-2020-323609] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/04/2021] [Indexed: 12/22/2022]
Abstract
Gut function remains largely underinvestigated in undernutrition, despite its critical role in essential nutrient digestion, absorption and assimilation. In areas of high enteropathogen burden, alterations in gut barrier function and subsequent inflammatory effects are observable but remain poorly characterised. Environmental enteropathy (EE)-a condition that affects both gut morphology and function and is characterised by blunted villi, inflammation and increased permeability-is thought to play a role in impaired linear growth (stunting) and severe acute malnutrition. However, the lack of tools to quantitatively characterise gut functional capacity has hampered both our understanding of gut pathogenesis in undernutrition and evaluation of gut-targeted therapies to accelerate nutritional recovery. Here we survey the technology landscape for potential solutions to improve assessment of gut function, focussing on devices that could be deployed at point-of-care in low-income and middle-income countries (LMICs). We assess the potential for technological innovation to assess gut morphology, function, barrier integrity and immune response in undernutrition, and highlight the approaches that are currently most suitable for deployment and development. This article focuses on EE and undernutrition in LMICs, but many of these technologies may also become useful in monitoring of other gut pathologies.
Collapse
Affiliation(s)
- Alex J Thompson
- Hamlyn Centre for Robotic Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Claire D Bourke
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
| | - Ruairi C Robertson
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
| | - Nirupama Shivakumar
- Division of Nutrition, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | | | - Tom Preston
- Stable Isotope Biochemistry Laboratory, Scottish Universities Environmental Research Centre, East Kilbride, UK
| | - Elaine Holmes
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Paul Kelly
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Gary Frost
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Douglas J Morrison
- Stable Isotope Biochemistry Laboratory, Scottish Universities Environmental Research Centre, East Kilbride, UK
| |
Collapse
|
12
|
Bona MD, Torres CHDM, Lima SCVC, Lima AAM, Maciel BLL. Intestinal barrier function in obesity with or without metabolic syndrome: a systematic review protocol. BMJ Open 2021; 11:e043959. [PMID: 34020973 PMCID: PMC8144043 DOI: 10.1136/bmjopen-2020-043959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Intestinal barrier function is dependent on the structure and function of intestinal epithelial cells and paracellular pathway. The derangement of the intestinal barrier function can originate from conditions involving local and systemic chronic inflammation and metabolic diseases such as obesity and metabolic disorders. This study aims to describe a systematic review protocol investigating if obesity with or without metabolic syndrome is associated with an altered intestinal barrier function. METHODS AND ANALYSIS This protocol is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. The databases to be searched are PubMed, Embase, Scopus, Science Direct and Web of Science. The systematic review will include original articles with adults and the elderly, who present obesity with or without metabolic syndrome, that address the intestinal barrier function. Two independent reviewers will perform study selection, data extraction and methodological quality assessment. Key information will be tabulated and a narrative synthesis will be conducted. The Grading of Recommendation, Assessment, Development and Evaluation framework will be used to assess the quality of evidence concerning the associations between intestinal barrier function and obesity with or without metabolic syndrome. The present protocol will assist in producing a systematic review that addresses if obesity with or without metabolic syndrome alters intestinal barrier function. ETHICS AND DISSEMINATION No ethical statement will be required. The results will be disseminated through a peer-reviewed publication and conference presentations. PROSPERO REGISTRATION NUMBER CRD42020178658.
Collapse
Affiliation(s)
- Mariana Duarte Bona
- Institute of Biomedicine for Brazilian Semiarid, Faculty of Medicine, Federal University of Ceara, Fortaleza, Brazil
| | | | - Severina Carla Vieira Cunha Lima
- Department of Nutrition, Federal University of Rio Grande do Norte, Natal, Brazil
- Postgraduate Program in Nutrition, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Aldo Angelo Moreira Lima
- Institute of Biomedicine for Brazilian Semiarid, Faculty of Medicine, Federal University of Ceara, Fortaleza, Brazil
| | - Bruna Leal Lima Maciel
- Department of Nutrition, Federal University of Rio Grande do Norte, Natal, Brazil
- Postgraduate Program in Nutrition, Federal University of Rio Grande do Norte, Natal, Brazil
- Postgraduate Program in Health Sciences, Federal University of Rio Grande do Norte, Natal, Brazil
| |
Collapse
|
13
|
The contribution of environmental enteropathy to the global problem of micronutrient deficiency. Proc Nutr Soc 2021; 80:303-310. [PMID: 33663621 DOI: 10.1017/s0029665121000549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Sometimes referred to as hidden hunger, micronutrient deficiencies persist on a global scale. For some micronutrients this appears to be due to inadequate intake, for others intake may not match increased requirements. However, for most micronutrient deficiencies there is uncertainty as to the dominant driver, and the question about the contribution of malabsorption is open. Environmental enteropathy (EE), formerly referred to as tropical enteropathy and also referred to as environmental enteric dysfunction, is an asymptomatic disorder of small intestinal structure and function which is very highly prevalent in many disadvantaged populations. Recent studies of the pathology and microbiology of this disorder suggest that it is driven by very high pathogen burdens in children and adults living in insanitary environments and is characterised by major derangements of the epithelial cells of the intestinal mucosa. Transcriptomic data suggest that it may lead to impaired digestion and absorption of macronutrients. Given the very high prevalence of EE, marginal malabsorption could have large impacts at population scales. However, the relative contributions of inadequate soil and crop micronutrient contents, inadequate intake, malabsorption and increased requirements are unknown. Malabsorption may compromise attempts to improve micronutrient status, but with the exception of zinc there is currently little evidence to confirm that malabsorption contributes to micronutrient deficiency. Much further research is required to understand the role of malabsorption in hidden hunger, especially in very disadvantaged populations where these deficiencies are most prevalent.
Collapse
|
14
|
Choudhry N, Scott F, Edgar M, Sanger GJ, Kelly P. Reversal of Pathogen-Induced Barrier Defects in Intestinal Epithelial Cells by Contra-pathogenicity Agents. Dig Dis Sci 2021; 66:88-104. [PMID: 32034605 DOI: 10.1007/s10620-020-06121-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 01/29/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Environmental enteropathy (EE) is associated with stunting, impairment of responses to oral vaccines, and other adverse health consequences in young children throughout the developing world. EE is characterized by chronic low-grade intestinal inflammation and disrupted epithelial barrier integrity, partly resulting from dysregulation of tight junction proteins, observed in other enteropathies such as celiac disease. During EE, this dysregulation of tight junction expression amplifies translocation of pathogenic bacteria across the intestinal mucosa. AIMS The aim was to determine whether enteropathogen-mediated epithelial barrier failure can be ameliorated using contra-pathogenicity therapies. METHODS Intestinal epithelial barrier damage was assessed in Caco-2 cells incubated with three important enteropathogens identified in EE patients: Enteropathogenic Escherichia coli (EPEC), Citrobacter rodentium (C. rodentium), and Cryptosporidium parvum (C. parvum). Potential therapeutic molecules were tested to detect effects on transepithelial resistance (TER), bacterial translocation (BT), claudin-4 expression, and regulation of the inflammatory cytokine response. RESULTS All three enteropathogens compared to uninfected cells, reduced TER (EPEC; p < 0.0001, C. rodentium; p < 0.0001, C. parvum; p < 0.0007), reduced claudin-4 expression, and permitted BT (EPEC; p < 0.0001, C. rodentium; p < 0.0001, C. parvum; p < 0.0003) through the monolayer. Zinc, colostrum, epidermal growth factor, trefoil factor 3, resistin-like molecule-β, hydrocortisone, and the myosin light chain kinase inhibitor ML7 (Hexahydro-1-[(5-iodo-1-naphthalenyl)sulfonyl]-1H-1,4-diazepine hydrochloride); ML7) improved TER (up to 70%) and decreased BT (as much as 96%). Only zinc demonstrated modest antimicrobial activity. CONCLUSION The enteropathogens impaired intestinal-epithelial barrier integrity with dysregulation of claudin-4 and increased bacterial translocation. Enteropathogen-mediated damage was reduced using contra-pathogenicity agents which mitigated the effects of pathogens without direct antimicrobial activity.
Collapse
Affiliation(s)
- Naheed Choudhry
- Barts and The London School of Medicine, Queen Mary, University of London, London, E1 2AT, UK.
| | - Flora Scott
- Barts and The London School of Medicine, Queen Mary, University of London, London, E1 2AT, UK
| | - Meghan Edgar
- Gastroenterology Drug Discovery Unit, Takeda California, Inc., 10410 Science Center Drive, San Diego, CA, 92121, USA
| | - Gareth J Sanger
- Barts and The London School of Medicine, Queen Mary, University of London, London, E1 2AT, UK
- Gastroenterology Drug Discovery Unit, Takeda California, Inc., 10410 Science Center Drive, San Diego, CA, 92121, USA
| | - Paul Kelly
- Barts and The London School of Medicine, Queen Mary, University of London, London, E1 2AT, UK
| |
Collapse
|
15
|
Turpin W, Lee SH, Raygoza Garay JA, Madsen KL, Meddings JB, Bedrani L, Power N, Espin-Garcia O, Xu W, Smith MI, Griffiths AM, Moayyedi P, Turner D, Seidman EG, Steinhart AH, Marshall JK, Jacobson K, Mack D, Huynh H, Bernstein CN, Paterson AD, Croitoru K. Increased Intestinal Permeability Is Associated With Later Development of Crohn's Disease. Gastroenterology 2020; 159:2092-2100.e5. [PMID: 32791132 DOI: 10.1053/j.gastro.2020.08.005] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/21/2020] [Accepted: 08/04/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Increased intestinal permeability has been associated with Crohn's disease (CD), but it is not clear whether it is a cause or result of the disease. We performed a prospective study to determine whether increased intestinal permeability is associated with future development of CD. METHODS We assessed the intestinal permeability, measured by the urinary fractional excretion of lactulose-to-mannitol ratio (LMR) at recruitment in 1420 asymptomatic first-degree relatives (6-35 years old) of patients with CD (collected from 2008 through 2015). Participants were then followed up for a diagnosis of CD from 2008 to 2017, with a median follow-up time of 7.8 years. We analyzed data from 50 participants who developed CD after a median of 2.7 years during the study period, along with 1370 individuals who remained asymptomatic until October 2017. We used the Cox proportional hazards model to evaluate time-related risk of CD based on the baseline LMR. RESULTS An abnormal LMR (>0.03) was associated with a diagnosis of CD during the follow-up period (hazard ratio, 3.03; 95% CI, 1.64-5.63; P = 3.97 × 10-4). This association remained significant even when the test was performed more than 3 years before the diagnosis of CD (hazard ratio, 1.62; 95% CI, 1.051-2.50; P = .029). CONCLUSIONS Increased intestinal permeability is associated with later development of CD; these findings support a model in which altered intestinal barrier function contributes to pathogenesis. Abnormal gut barrier function might serve as a biomarker for risk of CD onset.
Collapse
Affiliation(s)
- Williams Turpin
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sun-Ho Lee
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Juan Antonio Raygoza Garay
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Jonathan B Meddings
- Department of Medicine, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Larbi Bedrani
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Namita Power
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Osvaldo Espin-Garcia
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Wei Xu
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle I Smith
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Moayyedi
- Department of Medicine, McMaster University, Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ernest G Seidman
- Inflammatory Bowel Disease Centre, Division of Gastroenterology, McGill University Health Centre, Montréal, Quebec, Canada
| | - A Hillary Steinhart
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John K Marshall
- Department of Medicine, McMaster University, Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Kevan Jacobson
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada; British Columbia Children's Hospital, Vancouver, British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Mack
- Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
| | - Hien Huynh
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Charles N Bernstein
- University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre and, Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Manitoba, Winnipeg, Canada
| | - Andrew D Paterson
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Genetics and Genome Biology, The Hospital for Sick Children Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Kenneth Croitoru
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
16
|
Lee GO, Schillinger R, Shivakumar N, Whyte S, Huq S, Ochieng Konyole S, Chileshe J, Paredes-Olortegui M, Owino V, Yazbeck R, Kosek MN, Kelly P, Morrison D. Optimisation, validation and field applicability of a 13C-sucrose breath test to assess intestinal function in environmental enteropathy among children in resource poor settings: study protocol for a prospective study in Bangladesh, India, Kenya, Jamaica, Peru and Zambia. BMJ Open 2020; 10:e035841. [PMID: 33203623 PMCID: PMC7674092 DOI: 10.1136/bmjopen-2019-035841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 05/08/2020] [Accepted: 10/23/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Environmental enteropathy (EE) is suspected to be a cause of growth faltering in children with sustained exposure to enteric pathogens, typically in resource-limited settings. A major hindrance to EE research is the lack of sensitive, non-invasive biomarkers. Current biomarkers measure intestinal permeability and inflammation, but not the functional capacity of the gut. Australian researchers have demonstrated proof of concept for an EE breath test based on using naturally 13C-enriched sucrose, derived from maize, to assay intestinal sucrase activity, a digestive enzyme that is impaired in villus blunting. Here, we describe a coordinated research project to optimise, validate and evaluate the usability of a breath test protocol based on highly enriched 13C-sucrose to quantify physiological dysfunction in EE in relevant target populations. METHODS AND ANALYSIS We use the 13C-sucrose breath test (13C-SBT) to evaluate intestinal sucrase activity in two phases. First, an optimisation and validation phase will (1) confirm that a 13C-SBT using highly enriched sucrose tracers reports similar information to the naturally enriched 13C-SBT; (2) examine the dose-response relationship of the test to an intestinal sucrase inhibitor; (3) validate the 13C-SBT in paediatric coeliac disease (4) validate the highly enriched 13C-SBT against EE defined by biopsy in adults and (5) validate the 13C-SBT against EE defined by the urinary lactulose:rhamnose ratio (LR) among children in Peru. Second, a cross-sectional study will be conducted in six resource-limited countries (Bangladesh, India, Jamaica, Kenya, Peru and Zambia) to test the usability of the optimised 13C-SBT to assess EE among 600 children aged 12-15 months old. ETHICS AND DISSEMINATION Ethical approval will be obtained from each participating study site. By working as a consortium, the test, if shown to be informative of EE, will demonstrate strong evidence for utility across diverse, low-income and middle-income country paediatric populations. TRIAL REGISTRATION NUMBER NCT04109352; Pre-results.
Collapse
Affiliation(s)
- Gwenyth O Lee
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert Schillinger
- Scottish Universities Environmental Research Centre, University of Glasgow, Glasgow, UK
| | - Nirupama Shivakumar
- Division of Nutrition, Saint John's Research Institute, Bangalore, Karnataka, India
| | - Sherine Whyte
- Caribbean Institute for Health Research (formerly, Tropical Medicine Research Institute), University of the West Indies at Mona, Mona, Saint Andrew, Jamaica
| | - Sayeeda Huq
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Justin Chileshe
- Department of Nutritional Sciences, Masinde Muliro University of Science and Technology, Kakamega, Kenya
| | - Maribel Paredes-Olortegui
- Research and Development Area, Asociaciόn Benéfica Proyectos de Informática, Salud, Medicina, y Agricultura (A.B. PRISMA), Iquitos, Loreto, Peru
| | - Victor Owino
- Nutritional and Health Related Environmental Studies Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Roger Yazbeck
- Department of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, South Australia, Australia
| | - Margaret N Kosek
- Research and Development Area, Asociaciόn Benéfica Proyectos de Informática, Salud, Medicina, y Agricultura (A.B. PRISMA), Iquitos, Loreto, Peru
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Paul Kelly
- Blizard Institute, Barts and The London School of Medicine, London, UK
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Lusaka, Zambia
| | - Douglas Morrison
- Scottish Universities Environmental Research Centre, University of Glasgow, Glasgow, UK
| |
Collapse
|
17
|
Chandwe K, Amadi B, Chipunza M, Zyambo M, Kelly P. Safety and Ethics in Endoscopic Studies in Children: Evidence From the BEECH Study in Zambia. J Trop Pediatr 2020; 67:5981785. [PMID: 33188430 PMCID: PMC7948385 DOI: 10.1093/tropej/fmaa074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Environmental enteropathy is an example of a poorly-understood intestinal disorder affecting millions of children worldwide, characterized by malabsorption and stunting. Although there is increasing interest in non-invasive means of assessing intestinal structure and function, the potential value of intestinal biopsy for histology, immunostaining, RNA sequencing and epigenetic work means that endoscopic biopsy remains extremely valuable. We here report our experience in the BEECH (Biomarkers of Environmental Enteropathy in CHildren) study of stunting in Zambia, in the belief that it may help address the knowledge gap regarding the safety of endoscopic biopsy in vulnerable young children. METHODS We report our experience of safety in 119 children undergoing endoscopic biopsy in the BEECH study in Lusaka Children's Hospital, Lusaka, and discuss ethical considerations in this light. RESULTS Upper gastrointestinal endoscopy was performed on children with stunting (length-for-age z score -2 or less) not responsive to nutritional interventions. Conscious sedation was provided by anaesthetists. Of 119 children, 5 (4%) developed transient desaturation, but no serious adverse events were experienced; no clinical, demographic or anaesthetic characteristics were identified as predictive of desaturation. Two children derived clinically useful information from the endoscopy, one life-saving. Of 105 lactase tests, 59 (54%) showed hypolactasia. DISCUSSION Children with stunting underwent endoscopy safely, and some derived clinical benefit. Safety and the possibility of clinical benefit are usually felt to be preconditions for the ethical justification for endoscopy for research in children, and we believe that these conditions were met in this study.
Collapse
Affiliation(s)
- Kanta Chandwe
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia,Correspondence: Kanta Chandwe, MMed. Paeds. Tropical Gastroenterology & Nutrition Group (TROPGAN), University of Zambia, School of Medicine. Lusaka 10101, ZAMBIA. Tel: +260-966-806-816. E-mail:
| | - Beatrice Amadi
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia
| | - Miyoba Chipunza
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia
| | - Masuzyo Zyambo
- Department of Anaesthesia, University of Zambia School of Medicine, 10101 Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia,Barts & The London School of Medicine, Queen Mary University of London, London E1 2AT, UK
| |
Collapse
|
18
|
Statelova M, Holm R, Fotaki N, Reppas C, Vertzoni M. Successful Extrapolation of Paracetamol Exposure from Adults to Infants After Oral Administration of a Pediatric Aqueous Suspension Is Highly Dependent on the Study Dosing Conditions. AAPS JOURNAL 2020; 22:126. [DOI: 10.1208/s12248-020-00504-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/18/2020] [Indexed: 01/10/2023]
|
19
|
Intervention and Mechanisms of Alanyl-glutamine for Inflammation, Nutrition, and Enteropathy: A Randomized Controlled Trial. J Pediatr Gastroenterol Nutr 2020; 71:393-400. [PMID: 32826717 PMCID: PMC8576339 DOI: 10.1097/mpg.0000000000002834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Determine the minimum dosage of alanyl-glutamine (Ala-Gln) required to improve gut integrity and growth in children at risk of environmental enteropathy (EE). METHODS This was a double-blinded randomized placebo-controlled dose-response trial. We enrolled 140 children residing in a low-income community in Fortaleza, Brazil. Participants were 2 to 60 months old and had weight-for-age (WAZ), height-for-age (HAZ), or weight-for-height (WHZ) z-scores less than -1. We randomized children to 10 days of nutritional supplementation: Ala-Gln at 3 g/day, Ala-Gln at 6 g/day, Ala-Gln at 12 g/day, or an isonitrogenous dose of glycine (Gly) placebo at 12.5 g/day. Our primary outcome was urinary lactulose-mannitol excretion testing. Secondary outcomes were anthropometry, fecal markers of inflammation, urine metabolic profiles, and malabsorption (spot fecal energy). RESULTS Of 140 children, 103 completed 120 days of follow-up (24% dropout). In the group receiving the highest dose of Ala-Gln, we detected a modest improvement in urinary lactulose excretion from 0.19% on day 1 to 0.17% on day 10 (P = 0.05). We observed significant but transient improvements in WHZ at day 10 in 2 Ala-Gln groups, and in WHZ and WAZ in all Ala-Gln groups at day 30. We detected no effects on fecal inflammatory markers, diarrheal morbidity, or urine metabolic profiles; but did observe modest reductions in fecal energy and fecal lactoferrin in participants receiving Ala-Gln. CONCLUSIONS Intermediate dose Ala-Gln promotes short-term improvement in gut integrity and ponderal growth in children at risk of EE. Lower doses produced improvements in ponderal growth in the absence of enhanced gut integrity.
Collapse
|
20
|
Costa PN, Soares AM, Filho JQ, Junior FS, Ambikapathi R, Rogawski McQuade ET, Guerrant RL, Caulfield LE, Lima AAM, Maciel BLL. Dietary intake from complementary feeding is associated with intestinal barrier function and environmental enteropathy in Brazilian children from the MAL-ED cohort study. Br J Nutr 2020; 123:1003-1012. [PMID: 31964426 PMCID: PMC7282865 DOI: 10.1017/s0007114520000215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 12/26/2019] [Accepted: 01/07/2020] [Indexed: 12/19/2022]
Abstract
A child's diet contains nutrients and other substances that influence intestinal health. The present study aimed to evaluate the relations between complementary feeding, intestinal barrier function and environmental enteropathy (EE) in infants. Data from 233 children were obtained from the Brazilian site of the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project cohort study. Habitual dietary intake from complementary feeding was estimated using seven 24-h dietary recalls, from 9 to 15 months of age. Intestinal barrier function was assessed using the lactulose-mannitol test (L-M), and EE was determined as a composite measure using faecal biomarkers concentrations - α-1-antitrypsin, myeloperoxidase (MPO) and neopterin (NEO) at 15 months of age. The nutrient adequacies explored the associations between dietary intake and the intestinal biomarkers. Children showed adequate nutrient intakes (with the exception of fibre), impaired intestinal barrier function and intestinal inflammation. There was a negative correlation between energy adequacy and L-M (ρ = -0·19, P < 0·05) and between folate adequacy and NEO concentrations (ρ = -0·21, P < 0·01). In addition, there was a positive correlation between thiamine adequacy and MPO concentration (ρ = 0·22, P < 0·01) and between Ca adequacy and NEO concentration (ρ = 0·23; P < 0·01). Multiple linear regression models showed that energy intakes were inversely associated with intestinal barrier function (β = -0·19, P = 0·02), and fibre intake was inversely associated with the EE scores (β = -0·20, P = 0·04). Findings suggest that dietary intake from complementary feeding is associated with decreased intestinal barrier function and EE in children.
Collapse
Affiliation(s)
- P. N. Costa
- Nutrition Post-Graduation Program, Department of Nutrition, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - A. M. Soares
- Department of Physiology and Pharmacology, INCT – Instituto de Biomedicina do Semiárido Brasileiro (IBISAB), Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - J. Q. Filho
- Department of Physiology and Pharmacology, INCT – Instituto de Biomedicina do Semiárido Brasileiro (IBISAB), Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - F. S. Junior
- Department of Physiology and Pharmacology, INCT – Instituto de Biomedicina do Semiárido Brasileiro (IBISAB), Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - R. Ambikapathi
- Department of Public Health, Purdue University, West Lafayette, IN, USA
| | | | - R. L. Guerrant
- Center for Global Health, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - L. E. Caulfield
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - A. A. M. Lima
- Department of Public Health, Purdue University, West Lafayette, IN, USA
| | - B. L. L. Maciel
- Nutrition Post-Graduation Program, Department of Nutrition, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| |
Collapse
|
21
|
Bardosh KL, Hussein JW, Sadik EA, Hassen JY, Ketema M, Ibrahim AM, McKune SL, Havelaar AH. Chicken eggs, childhood stunting and environmental hygiene: an ethnographic study from the Campylobacter genomics and environmental enteric dysfunction (CAGED) project in Ethiopia. ONE HEALTH OUTLOOK 2020; 2:5. [PMID: 33829128 PMCID: PMC7993501 DOI: 10.1186/s42522-020-00012-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/20/2020] [Indexed: 05/28/2023]
Abstract
BACKGROUND Childhood stunting and malnutrition condemn millions of people globally to a life of disadvantage and cognitive and physical impairment. Though increasing egg consumption is often seen as an important solution for low and middle income countries (including Ethiopia), emerging evidence suggests that greater exposure to poultry feces may also inhibit child growth due to the effects of enteric bacteria, especially Campylobacter, on gut health. METHODS In this rapid ethnographic study, we explored village poultry production, child dietary practices, and environmental hygiene conditions as they relate to Campylobacter risk and intervention in 16 villages in Haramaya Woreda, Eastern Ethiopia. RESULTS In the study area, we found that women assumed primary responsibility to care for both chickens and children: in feeding, housing, and healthcare. Most chickens were free-range local indigenous breeds, and flock sizes were small and unstable due to epidemics, seasonal trends, reproductive patterns, and lack of food. Generally, eggs were seen as "too luxurious" to be eaten, and were predominantly sold at local markets for scarce cash, despite high malnutrition rates. Local narratives of extreme poverty, social dietary norms, parental fatalism, and lack of "dietary consciousness" (as it was called) were invoked to explain this. We found that homesteads were highly contaminated with human and animal feces. Although community members viewed chicken feces and poultry gastrointestinal contents as particularly noxious in comparison to other animals because of their feeding behaviour, they did not relate them to any particular disease. Shared human-animal housing and childcare practices place children at high risk of exposure to enteric bacteria from animal manure, despite daily routines designed to manage the domestic landscape. CONCLUSIONS Addressing childhood stunting and malnutrition through egg production in rural landscapes like Haramaya must navigate three distinct health and care regimes: for children, chickens, and home environments. Interventions should be based on a holistic approach to social and economic empowerment, one that considers both women and men and integrates nutrition, health, and community change as its overarching goal.
Collapse
Affiliation(s)
- Kevin Louis Bardosh
- Department of Anthropology, University of Florida, Gainesville, USA
- Center for One Health Research, School of Public Health, University of Washington, Seattle, USA
| | | | - Elias Ahmed Sadik
- College of Social Sciences and Humanities, Haramaya University, Dire Dawa, Ethiopia
| | - Jemal Yousuf Hassen
- Department of Rural Development and Agricultural Extension, Haramaya University, Dire Dawa, Ethiopia
| | - Mengistu Ketema
- School of Agricultural Economics and Agribusiness Management, Haramaya University, Dire Dawa, Ethiopia
| | | | | | - Arie Hendrik Havelaar
- Department of Animal Sciences, Emerging Pathogens Institute, Institute for Sustainable Food Systems, University of Florida, Gainesville, USA
| |
Collapse
|
22
|
McCormick BJJ, Murray-Kolb LE, Lee GO, Schulze KJ, Ross AC, Bauck A, Lima AAM, Maciel BLL, Kosek MN, Seidman JC, Ambikapathi R, Bose A, John S, Kang G, Turab A, Mduma E, Bessong P, Shrestra SK, Ahmed T, Mahfuz M, Olortegui MP, Bhutta Z, Caulfield LE. 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. Am J Clin Nutr 2019; 110:1015-1025. [PMID: 31565748 PMCID: PMC6766446 DOI: 10.1093/ajcn/nqz151] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 06/24/2019] [Indexed: 12/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Laura E Murray-Kolb
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, USA
| | - Gwenyth O Lee
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kerry J Schulze
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - A Catharine Ross
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, USA
| | - Aubrey Bauck
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Aldo A M Lima
- Universidade Federal do Ceará, INCT—Instituto de Biomedicina do Semiárido Brasileiro, Fortaleza, Brazil
| | - Bruna L L Maciel
- Department of Nutrition, Federal University of Rio Grande do Norte, Natal, Rio Negro, Brazil
| | - Margaret N Kosek
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Anuradha Bose
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Sushil John
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Gagandeep Kang
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Ali Turab
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | - Sanjaya K Shrestra
- Walter Reed, Armed Forces Research Institute of Medical Sciences (AFRIMS) Research Unit, Nepal (WARUN), Kathmandu, Nepal
| | - Tahmeed Ahmed
- Division of Nutrition and Clinical Services, icddr,b, Dhaka, Bangladesh
| | - Mustafa Mahfuz
- Division of Nutrition and Clinical Services, icddr,b, Dhaka, Bangladesh
| | | | - Zulfiqar Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Laura E Caulfield
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Address correspondence to LEC (E-mail: )
| | | |
Collapse
|
23
|
Raqib R, Sarker P, Zaman K, Alam NH, Wierzba TF, Maier N, Talukder K, Baqui AH, Suvarnapunya AE, Qadri F, Walker RI, Fix A, Venkatesan MM. A phase I trial of WRSS1, a Shigella sonnei live oral vaccine in Bangladeshi adults and children. Hum Vaccin Immunother 2019; 15:1326-1337. [PMID: 30794051 DOI: 10.1080/21645515.2019.1575165] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Shigella sonnei live vaccine candidate, WRSS1, which was previously evaluated in US, Israeli and Thai volunteers, was administered orally to Bangladeshi adults and children to assess its safety, clinical tolerability and immunogenicity. In a randomized, placebo-controlled, dose-escalation, age-descending study, 39 adults (18-39 years) and 64 children (5-9 years) were enrolled. Each adult cohort (n = 13) received one dose of 3x104, or three doses of 3 × 105 or 3 × 106 colony forming unit (CFU) of WRSS1 (n = 10) or placebo (n = 3). Each child cohort (n = 16) received one dose of 3x103, or three doses of 3x104, 3x105, or 3 × 106 CFU WRSS1 (n = 12) or placebo (n = 4). WRSS1 elicited mostly mild and transient reactogenicity events in adults and children. In the 3 × 106 dose group, 50% of the adults shed the vaccine; no shedding was seen in children. At the highest dose, 100% of adults and 40% of children responded with a ≥ 4-fold increase of S. sonnei LPS-specific IgA antibody in lymphocyte supernatant (ALS). At the same dose, 63% of adults and 70% of children seroconverted with IgA to LPS, while in placebo, 33% of adults and 18% of children seroconverted. Both the vaccinees and placebos responded with fecal IgA to LPS, indicating persistent exposure to Shigella infections. In conclusion, WRSS1 was found safe up to 106 CFU dose and immunogenic in adults and children in Bangladesh. These data indicate that live, oral Shigella vaccine candidates, including WRSS1 can potentially be evaluated in toddlers and infants (<2 years of age), who comprise the target population in an endemic environment.
Collapse
Affiliation(s)
- Rubhana Raqib
- a Infectious Diseases Division , icddr,b , Dhaka , Bangladesh
| | - Protim Sarker
- a Infectious Diseases Division , icddr,b , Dhaka , Bangladesh
| | - K Zaman
- a Infectious Diseases Division , icddr,b , Dhaka , Bangladesh
| | - Nur Haque Alam
- b Nutrition and Clinical Services Division , icddr,b , Dhaka , Bangladesh
| | - Thomas F Wierzba
- c Center for Vaccine Innovation and Access , PATH , Washington , DC , USA
| | - Nicole Maier
- c Center for Vaccine Innovation and Access , PATH , Washington , DC , USA
| | - Kaisar Talukder
- d Laboratory Sciences and Services Division , icddr,b , Dhaka , Bangladesh
| | - Abdullah Hel Baqui
- e Johns Hopkins Bloomberg School of Public Health , Johns Hopkins University , Baltimore , MD , USA
| | - Akamol E Suvarnapunya
- f Bacterial Diseases Branch , Walter Reed Army Institute of Research , Silver Spring , MD , USA
| | - Firdausi Qadri
- a Infectious Diseases Division , icddr,b , Dhaka , Bangladesh
| | - Richard I Walker
- c Center for Vaccine Innovation and Access , PATH , Washington , DC , USA
| | - Alan Fix
- c Center for Vaccine Innovation and Access , PATH , Washington , DC , USA
| | - Malabi M Venkatesan
- f Bacterial Diseases Branch , Walter Reed Army Institute of Research , Silver Spring , MD , USA
| |
Collapse
|
24
|
Pan WK, Seidman JC, Ali A, Hoest C, Mason C, Mondal D, Knobler SL, Bessong P. Oral polio vaccine response in the MAL-ED birth cohort study: Considerations for polio eradication strategies. Vaccine 2018; 37:352-365. [PMID: 30442479 PMCID: PMC6325791 DOI: 10.1016/j.vaccine.2018.05.080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/15/2018] [Accepted: 05/17/2018] [Indexed: 11/28/2022]
Abstract
Background Immunization programs have leveraged decades of research to maximize oral polio vaccine (OPV) response. Moving toward global poliovirus eradication, the WHO recommended phased OPV-to-IPV replacement on schedules in 2012. Using the MAL-ED prospective birth cohort data, we evaluated the influence of early life exposures impacting OPV immunization by measuring OPV response for serotypes 1 and 3. Methods Polio neutralizing antibody assays were conducted at 7 and 15 months of age for serotypes 1 and 3. Analyses were conducted on children receiving ≥3 OPV doses (n = 1449). History of vaccination, feeding patterns, physical growth, home environment, diarrhea, enteropathogen detection, and gut inflammation were examined as risk factors for non-response [Log2(titer) < 3] and Log2(titer) by serotype using multivariate regression. Findings Serotype 1 seroconversion was significantly higher than serotype 3 (96.6% vs. 89.6%, 15 months). Model results indicate serotypes 1 and 3 failure was minimized following four and six OPV doses, respectively; however, enteropathogen detection and poor socioeconomic conditions attenuated response in both serotypes. At three months of age, bacterial detection in stool reduced serotype 1 and 3 Log2 titers by 0.34 (95% CI 0.14–0.54) and 0.53 (95% CI 0.29–0.77), respectively, and increased odds of serotype 3 failure by 3.0 (95% CI 1.6–5.8). Our socioeconomic index, consisting of Water, Assets, Maternal education, and Income (WAMI), was associated with a 0.79 (95% CI 0.15–1.43) and 1.23 (95% CI 0.34–2.12) higher serotype 1 and 3 Log2 titer, respectively, and a 0.04 (95% CI 0.002–0.40) lower odds of serotype 3 failure. Introduction of solids, transferrin receptor, and underweight were differentially associated with serotype response. Other factors, including diarrheal frequency and breastfeeding practices, were not associated with OPV response. Interpretation Under real-world conditions, improved vaccination coverage and socio-environmental conditions, and reducing early life bacterial exposures are key to improving OPV response and should inform polio eradication strategies.
Collapse
Affiliation(s)
- William K Pan
- Duke Global Health Institute, Duke University, Trent Hall, 310 Trent Drive, Durham, NC 27710, USA.
| | - Jessica C Seidman
- Fogarty International Center/National Institutes of Health, Bethesda, MD, USA
| | - Asad Ali
- Aga Khan University, Karachi, Pakistan
| | - Christel Hoest
- Fogarty International Center/National Institutes of Health, Bethesda, MD, USA
| | - Carl Mason
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | - Stacey L Knobler
- Fogarty International Center/National Institutes of Health, Bethesda, MD, USA
| | | | | |
Collapse
|
25
|
Marie C, Ali A, Chandwe K, Petri WA, Kelly P. Pathophysiology of environmental enteric dysfunction and its impact on oral vaccine efficacy. Mucosal Immunol 2018; 11:1290-1298. [PMID: 29988114 DOI: 10.1038/s41385-018-0036-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 02/08/2023]
Abstract
Environmental enteric dysfunction (EED) refers to a subclinical disorder of intestinal function common in tropical countries and in settings of poverty and economic disadvantage. The enteropathy that underlies this syndrome is characterized by mucosal inflammation and villus blunting mediated by T cell activation. Epithelial cell disruption and microbial translocation drive systemic inflammation. EED in young children is associated geographically with growth failure, malnutrition, and greatly impaired responses to oral vaccines, notably rotavirus and poliovirus vaccines. In this review, we describe the pathophysiology of EED and examine the evidence linking EED and oral vaccine failure. This evidence is far from conclusive. Although our understanding of EED is still sketchy, there is limited evidence of disturbed innate immunity, B cell disturbances including aggregation into lymphoid follicles, and autoantibody generation. Pathways of T cell activation and the possibility of dendritic cell anergy, which could help explain oral vaccine failure, require further work.
Collapse
Affiliation(s)
- Chelsea Marie
- The University of Virginia, Charlottesville, VA, USA
| | - Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | | | - Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia. .,Barts & The London School of Medicine, Queen Mary University of London, London, E1 4AT, UK.
| |
Collapse
|
26
|
Vonaesch P, Randremanana R, Gody JC, Collard JM, Giles-Vernick T, Doria M, Vigan-Womas I, Rubbo PA, Etienne A, Andriatahirintsoa EJ, Kapel N, Brown E, Huus KE, Duffy D, Finlay B, Hasan M, Hunald FA, Robinson A, Manirakiza A, Wegener-Parfrey L, Vray M, Sansonetti PJ. Identifying the etiology and pathophysiology underlying stunting and environmental enteropathy: study protocol of the AFRIBIOTA project. BMC Pediatr 2018; 18:236. [PMID: 30025542 PMCID: PMC6053792 DOI: 10.1186/s12887-018-1189-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/21/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Globally one out of four children under 5 years is affected by linear growth delay (stunting). This syndrome has severe long-term sequelae including increased risk of illness and mortality and delayed psychomotor development. Stunting is a syndrome that is linked to poor nutrition and repeated infections. To date, the treatment of stunted children is challenging as the underlying etiology and pathophysiological mechanisms remain elusive. We hypothesize that pediatric environmental enteropathy (PEE), a chronic inflammation of the small intestine, plays a major role in the pathophysiology of stunting, failure of nutritional interventions and diminished response to oral vaccines, potentially via changes in the composition of the pro- and eukaryotic intestinal communities. The main objective of AFRIBIOTA is to describe the intestinal dysbiosis observed in the context of stunting and to link it to PEE. Secondary objectives include the identification of the broader socio-economic environment and biological and environmental risk factors for stunting and PEE as well as the testing of a set of easy-to-use candidate biomarkers for PEE. We also assess host outcomes including mucosal and systemic immunity and psychomotor development. This article describes the rationale and study protocol of the AFRIBIOTA project. METHODS AFRIBIOTA is a case-control study for stunting recruiting children in Bangui, Central African Republic and in Antananarivo, Madagascar. In each country, 460 children aged 2-5 years with no overt signs of gastrointestinal disease are recruited (260 with no growth delay, 100 moderately stunted and 100 severely stunted). We compare the intestinal microbiota composition (gastric and small intestinal aspirates; feces), the mucosal and systemic immune status and the psychomotor development of children with stunting and/or PEE compared to non-stunted controls. We also perform anthropological and epidemiological investigations of the children's broader living conditions and assess risk factors using a standardized questionnaire. DISCUSSION To date, the pathophysiology and risk factors of stunting and PEE have been insufficiently investigated. AFRIBIOTA will add new insights into the pathophysiology underlying stunting and PEE and in doing so will enable implementation of new biomarkers and design of evidence-based treatment strategies for these two syndromes.
Collapse
Affiliation(s)
- Pascale Vonaesch
- Unité de Pathogénie Microbienne Moléculaire, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| | - Rindra Randremanana
- Unité d’Epidémiologie et de Recherche Clinique, Institut Pasteur de Madagascar, BP 1274 Ambatofotsikely, Avaradoha, 101 Antananarivo, Madagascar
| | - Jean-Chrysostome Gody
- Centre Pédiatrique de Bangui, Avenue de l’Indépendance, Bangui, Central African Republic
| | - Jean-Marc Collard
- Unité de Bactériologie Expérimentale, Institut Pasteur de Madagascar, BP 1274 Ambatofotsikely, Avaradoha, 101 Antananarivo, Madagascar
| | - Tamara Giles-Vernick
- Unité d’Epidémiologie des Maladies Emergentes, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| | - Maria Doria
- Unité de Pathogénie Microbienne Moléculaire, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| | - Inès Vigan-Womas
- Unité d’Immunologie des Maladies Infectieuses, Institut Pasteur de Madagascar, BP 1274 Ambatofotsikely, Avaradoha, 101 Antananarivo, Madagascar
| | - Pierre-Alain Rubbo
- Laboratoire d’Analyses Médicales, Institut Pasteur de Bangui, Avenue de l’Indépendance, Bangui, Central African Republic
| | - Aurélie Etienne
- Unité d’Epidémiologie et de Recherche Clinique, Institut Pasteur de Madagascar, BP 1274 Ambatofotsikely, Avaradoha, 101 Antananarivo, Madagascar
| | - Emilson Jean Andriatahirintsoa
- Centre Hospitalier Universitaire Mère-Enfant de Tsaralalàna (CHUMET), rue Patrice Lumumba, Tsaralalàna, 101 Antananarivo, Madagascar
| | - Nathalie Kapel
- Laboratoire de Coprologie Fonctionnelle, Hôpital Pitié-Salpêtrière, 47-83 Bd de l’Hôpital, 75013 Paris, France
| | - Eric Brown
- Michael Smith Laboratories, University of British Columbia, 2185 East Mall, Vancouver, V6T1Z4 Canada
| | - Kelsey E. Huus
- Michael Smith Laboratories, University of British Columbia, 2185 East Mall, Vancouver, V6T1Z4 Canada
| | - Darragh Duffy
- Unité de la Biologie des Cellules Dendritiques, Institut Pasteur, 25 Rue du Dr. Roux, 75015 Paris, France
| | - B.Brett Finlay
- Michael Smith Laboratories, University of British Columbia, 2185 East Mall, Vancouver, V6T1Z4 Canada
| | - Milena Hasan
- Centre de Recherche Translationnelle, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| | - Francis Allen Hunald
- Centre Hospitalier Universitaire Joseph Ravoahangy Andrianavalona (CHUJRA), Antananarivo, Madagascar
| | - Annick Robinson
- Centre Hospitalier Universitaire Mère Enfant de Tsaralalana, Antananarivo, Madagascar
| | - Alexandre Manirakiza
- Unité d’Epidémiologie, Institut Pasteur de Bangui, Avenue de l’Indépendance, Bangui, Central African Republic
| | - Laura Wegener-Parfrey
- Departments of Botany and Zoology, and Biodiversity Research Centre, University of British Columbia, 3200-6270 University Boulevard, Vancouver, V6T1Z4 Canada
| | - Muriel Vray
- Unité d’Epidémiologie des Maladies Emergentes, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| | - Philippe J. Sansonetti
- Unité de Pathogénie Microbienne Moléculaire, Institut Pasteur, 28 Rue du Dr. Roux, 75015 Paris, France
| |
Collapse
|
27
|
Sié A, Dah C, Ouermi L, Tapsoba C, Zabre P, Bärnighausen T, Lebas E, Arzika AM, Snyder BM, Porco TC, Lietman TM, Keenan JD, Oldenburg CE. Effect of Antibiotics on Short-Term Growth among Children in Burkina Faso: A Randomized Trial. Am J Trop Med Hyg 2018; 99:789-796. [PMID: 30014828 DOI: 10.4269/ajtmh.18-0342] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Antibiotics improve both weight and height gain in randomized trials of preschool children with preexisting morbidity. Here, we assess the effect of a short course of three different antibiotics (amoxicillin, azithromycin, and cotrimoxazole) on short-term linear and ponderal growth in a population-based sample of preschool children in rural Burkina Faso. We randomized households with at least two children in the Nouna district, Burkina Faso, to a 5-day course of amoxicillin, azithromycin, cotrimoxazole, or placebo. Within each antibiotic-randomized household, one child was randomly assigned to receive the antibiotic and the other to receive the placebo. Weight and height measurements were taken at baseline and 30 days following the last study medication dose. Weight-for-height Z (WHZ), height-for-age Z (HAZ), and weight-for-age Z (WAZ) scoreswere calculated based on the 2006 World Health Organization standards. Of the 124 households and 248 children enrolled, 229 had anthropometry measurements at 1 month and were analyzed. Children randomized to amoxicillin gained significantly more weight compared with both the placebo household (mean difference 317 g, 95% confidence interval [CI]: 115-519 g) and placebo sibling (mean difference 315 g, 95% CI: 147-482 g) controls. Growth velocity in g/kg/day, and WHZ and WAZ scores were higher in amoxicillin-treated children compared with placebo households and siblings. There were no differences in weight gain in children randomized to azithromycin or cotrimoxazole compared with placebo households or placebo siblings. There were no differences in height gain or HAZ across any of the study arms. Amoxicillin may have short-term growth-promoting effects in healthy children.
Collapse
Affiliation(s)
- Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | | | - Pascal Zabre
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | | | - Blake M Snyder
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Travis C Porco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Thomas M Lietman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Jeremy D Keenan
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Catherine E Oldenburg
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation, University of California, San Francisco, California
| |
Collapse
|
28
|
Environmental enteric dysfunction and systemic inflammation predict reduced weight but not length gain in rural Bangladeshi children. Br J Nutr 2018; 119:407-414. [DOI: 10.1017/s0007114517003683] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AbstractEnvironmental enteric dysfunction (EED) and systemic inflammation (SI) are common in developing countries and may cause stunting. In Bangladesh, >40 % of preschool children are stunted, but EED and SI contributions are unknown. We aimed to determine the impact of EED and SI (assessed with multiple indicators) on growth in children (n 539) enrolled in a community-based randomised food supplementation trial in rural Bangladesh. EED was defined with faecal myeloperoxidase, α-1 antitrypsin and neopterin and serum endotoxin core antibody and glucagon-like peptide-2, consolidated into gut inflammation (GI) and permeability (GP) scores, and urinary lactulose:mannitol α-1 acid glycoprotein (AGP) characterised SI. Biomarker associations with anthropometry (15-, 18- and 24-month length-for-age (LAZ), weight-for-length (WLZ) and weight-for-age (WAZ) z scores) were examined in pairwise correlations and adjusted mixed-effects regressions. Stunting, wasting and underweight prevalence at 18 months were 45, 15 and 37 %, respectively, with elevated EED and SI markers common. EED and SI were not associated with 15–24-month length trajectory. Elevated (worse) GI and GP scores predicted reduced 18–24-month WLZ change (β −0·01 (se 0·00) z score/month for both). Elevated GP was also associated with reduced 15–18-month WLZ change (β −0·03 (se 0·01) z score/month) and greater 15-month WLZ (β 0·16 (se 0·05)). Higher AGP was associated with reduced prior and increased subsequent WLZ change (β −0·04 (se 0·01) and β 0·02 (se 0·00) z score/month for 15–18 and 18–24 months). The hypothesised link from EED to stunting was not observed in this sample of Bangladeshi 18-month-olds, but the effects of EED on constrained weight gain may have consequences for later linear growth or for other health and development outcomes.
Collapse
|