Contribution of enteric infection, altered intestinal barrier function, and maternal malnutrition to infant malnutrition in Bangladesh

Abstract

Background: Malnourished children are at increased risk for death due to diarrhea. Our goal was to determine the contribution of specific enteric infections to malnutrition-associated diarrhea and to determine the role of enteric infections in the development of malnutrition.

Methods: Children from an urban slum in Bangladesh were followed for the first year of life by every-other-day home visits. Enteropathogens were identified in diarrheal and monthly surveillance stools; intestinal barrier function was measured by serum endocab antibodies; and nutritional status was measured by anthropometry.

Results: Diarrhea occurred 4.69 ± 0.19 times per child per year, with the most common infections caused by enteric protozoa (amebiasis, cryptosporidiosis, and giardiasis), rotavirus, astrovirus, and enterotoxigenic Escherichia coli (ETEC). Malnutrition was present in 16.3% of children at birth and 42.4% at 12 months of age. Children malnourished at birth had increased Entamoeba histolytica, Cryptosporidium, and ETEC infections and more severe diarrhea. Children who became malnourished by 12 months of age were more likely to have prolonged diarrhea, intestinal barrier dysfunction, a mother without education, and low family expenditure.

Conclusions: Prospective observation of infants in an urban slum demonstrated that diarrheal diseases were associated with the development of malnutrition that was in turn linked to intestinal barrier disruption and that diarrhea was more severe in already malnourished children. The enteric protozoa were unexpectedly important causes of diarrhea in this setting. This study demonstrates the complex interrelationship of malnutrition and diarrhea in infants in low-income settings and points to the potential for infectious disease interventions in the prevention and treatment of malnutrition.

Figure 1.

Percentage of malnourished (WAZ <−2) and stunted (HAZ <−2) children with increasing age, from birth to 12 months. Infants were weighed and measured every 3 months, and HAZ and WAZ scores determined using the World Health Organization’s Anthro software, version 3.0.1.

Figure 2.

Cumulative percentage of children infected with Entamoeba histolytica, Giardia lamblia, Cryptosporidium, and rotavirus. Monthly surveillance and diarrhea stools were tested for Entamoeba histolytica, Giardia lamblia, and Cryptosporidium infection by real-time polymerase chain reaction and rotavirus by antigen detection.