Relationship between growth and illness, enteropathogens and dietary intakes in the first 2 years of life: findings from the MAL-ED birth cohort study

Abstract

BackgroundDietary and illness factors affect risk of growth faltering; the role of enteropathogens is less clear. As part of the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study, we quantify the effects of enteropathogen infection, diarrhoea and diet on child growth.MethodsNewborns were enrolled and followed until 24 months. Length and weight were assessed monthly. Illnesses and breastfeeding practices were documented biweekly; from 9 to 24 months, non-breast milk intakes were quantified monthly. Routinely collected non-diarrhoeal stools were analysed for a broad array of enteropathogens. A linear piecewise spline model was used to quantify associations of each factor with growth velocity in seven of eight MAL-ED sites; cumulative effects on attained size at 24 months were estimated for mean, low (10th percentile) and high (90th percentile) exposure levels. Additionally, the six most prevalent enteropathogens were evaluated for their effects on growth.ResultsDiarrhoea did not have a statistically significant effect on growth. Children with high enteropathogen exposure were estimated to be 1.21±0.33 cm (p<0.001; 0.39 length for age (LAZ)) shorter and 0.08±0.15 kg (p=0.60; 0.08 weight-for-age (WAZ)) lighter at 24 months, on average, than children with low exposure. Campylobacter and enteroaggregativeEscherichia coli detections were associated with deficits of 0.83±0.33 and 0.85±0.31 cm in length (p=0.011 and 0.001) and 0.22±0.15 and 0.09±0.14 kg in weight (p=0.14 and 0.52), respectively. Children with low energy intakes and protein density were estimated to be 1.39±0.33 cm (p<0.001; 0.42 LAZ) shorter and 0.81±0.15 kg (p<0.001; 0.65 WAZ) lighter at 24 months than those with high intakes.ConclusionsReducing enteropathogen burden and improving energy and protein density of complementary foods could reduce stunting.

Virulence-Related Genes and Coenteropathogens Associated with Clinical Outcomes of Enteropathogenic Escherichia coli Infections in Children from the Brazilian Semiarid Region: a Case-Control Study of Diarrhea

“…Importantly, Campylobacter spp. and EAEC were the two major enteropathogens associated with growth decrements in a large multicenter study of the etiology of environmental enteropathy in children from developing countries (44), and this study reinforces the major burden of these pathogens.…”

“…Other studies have tried to associate enteropathogens, including diarrheagenic E. coli, such as enteroaggregative E. coli (EAEC), with undernutrition in child populations (42,43). Recent data emerging from MAL-ED studies have reinforced the importance of even asymptomatic enteric infections as a cause of growth impairment in children from developing countries (44,45), which was observed due to the use of molecular diagnostic techniques instead of conventional techniques (46,47). Indeed, the higher prevalence of aEPEC than tEPEC in asymptomatic children was recently supported by Rogawski and colleagues (47) and requires further investigation.…”

Child malnutrition in Ifanadiana district, Madagascar: associated factors and timing of growth faltering ahead of a health system strengthening intervention

“…In addition, the high prevalence of poverty, illness, and poor sanitation combined with the high rates of malnutrition (69% of children in the sample had been ill or injured in the past 4 weeks alone, and 99% of households had either an open pit or no facility for toileting) may obscure individual-level effects which have been noted in international literature [12–16] instead acting as a population-level environmental risk for poor growth [15]. …”

“…In another study, community-level sanitation access protected from stunting regardless of household-level sanitation access [15], however poor sanitation at the household level also predicted stunting, supporting the importance of diarrheal illness and poor sanitation in malnutrition [15]. Gastrointestinal infection, even without symptoms such as diarrhea, is likely to play a role in stunting as well: a recent longitudinal study attributed linear growth faltering, which leads to stunting, to enteropathogen exposure, even in the absence of diarrheal illness [16]. Diet is also important, although it is less commonly associated with stunting or wasting in international literature, perhaps due to difficulties in studying nutritional intake [17].…”

“…Diet is also important, although it is less commonly associated with stunting or wasting in international literature, perhaps due to difficulties in studying nutritional intake [17]. However, some longitudinal research attributes both linear growth faltering and poor weight gain to low energy intake and low protein density [16]. Environmental factors such as rural residence [13,17], dry season, and local food shortages [18] all predict malnutrition in multiple studies.…”