Abstract. Clinical research on probiotics presents challenging issues for researchers, regulators, and funding agencies, and these issues become more complex when United States federally funded research is conducted outside the United States. Here, we describe the design and results of a Phase I safety study of Lactobacillus reuteri DSM 17938 conducted as a community-based trial under the Food and Drug Administration Investigative New Drug (FDA IND) program in a small town in the Peruvian Amazon. Forty-five healthy adults 18 to 65 years of age were randomized in a 2:1 ratio to receive either Lactobacillus reuteri 10 8 organisms once daily for 5 days or an identical appearing placebo. Results showed no evidence of invasive infection resulting from probiotic administration and no differences between groups. Although we encountered several challenges in conducting an FDA-approved safety trial in this setting, the rigorously collected contextually relevant data will be very valuable to support later Phase II/III studies of L. reuteri for use in similar settings.Probiotic products, including nutritional supplements and preparations designed to provide health benefits, have generated increased attention from both the biomedical community and the lay press during the last 10 years, as consumers in many countries are eager for alternative, natural, and cost-effective ways to improve health and prevent or treat diseases. [1][2][3][4] "Probiotics" are intended to contain non-pathogenic microorganisms generally administered orally to colonize the gastrointestinal tract, where they have the potential to improve health through modulating the microbiome. Human microbiome research has rekindled interest in probiotics, 5-8 as the structure of the microbiome is linked with metabolic phenotypes in the host, and thus the use of select probiotic organisms to orchestrate beneficial changes is gaining scientific support. 9 Clinical research on probiotics for prevention or treatment of human diseases, such as infectious diarrhea, presents new and challenging questions and issues for researchers, regulatory agencies, and funding agencies 10,11 ; most probiotic products are produced by food manufacturers and marketed as nutritional supplements, without claiming any specific health benefits. The U.S. Food and Drug Administration also categorized some of these probiotic preparations as "Generally Regarded as Safe or GRAS" products. The use of probiotics is broad in the extreme, and they are present in yogurt, beverages, dietary supplements, and animal feed in an increasing number of countries. However, when investigators in the United States evaluate the therapeutic effect of probiotics or any other products to treat, mitigate, prevent, or cure disease states, United States regulations determine that they are being used as pharmaceuticals for a medical indication, and regulates them accordingly. Pharmaceutical products to be used for medical indications are produced and controlled in a far more stringent way than food products and dietary...

IntroductionEnvironmental 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 analysisWe 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 disseminationEthical 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 numberNCT04109352; Pre-results.

Background Deworming programs aimed at reducing morbidity and mortality from geohelminth infections are common in many countries where these infections are endemic, but data demonstrating increasing levels of resistance to albendazole and mebendazole are causes for concern. Studies to evaluate the clinical efficacy of deworming programs are critical to maintain high infection control goals. Methods We propose to assess the clinical efficacy of Peruvian national guidelines for deworming programs in a prospective observational study conducted in the Amazon River basin area near Iquitos, Peru. Major outcomes to be evaluated include (1) albendazole resistance of intestinal helminths (trichuriasis, ascariasis, hookworm), and (2) frequency of reinfection with intestinal helminths 4 months after treatment with albendazole. Children ages 2–11 years from the Belén District of Iquitos will be identified based on a community census. Following parental informed consent, demographic data, weight, and height will be recorded and a stool specimen for parasitological exam by direct observation and Kato-Katz concentration method, and helminthic egg counts will be collected prior to administration of albendazole, following Peruvian national guidelines. Follow-up stool specimens examined in the same manner will be collected at 20 days, 90 days, and 100 days following initial administration of albendazole, and based on parasites found repeat treatment will be administered in accordance with national guidelines. Real-time multiplex qPCR will be performed on helminth positive samples collected prior to initial deworming and on helminth-positive specimens detected on day 15–20. A total sample size of 380 participants was calculated based on total population in the target group and prevalence estimates of helminth infections and clinical resistance based on recent data. Discussion Data from observational clinical efficacy studies are important to guide geohelminth infection control programs. Trial registrationhttps://www.researchregistry.com/. Identification number: researchregistry7736; Registered retrospectively March 13, 2022; https://www.researchregistry.com/browse-the-registry#home/registrationdetails/622e024cf06132001e3327bf/

Objectives Characterize relationships between dietary patterns and the cardiometabolic profile of Peruvian children at risk of undernutrition. Methods The study was nested in the Peru site of the ‘MAL-ED’ study, a longitudinal birth cohort to evaluate relationships between diet, enteric exposures and child growth and development. Dietary recalls were collected from 9–24 months of age. At 3–5 years, we conducted a follow-up. Three additional dietary recalls were collected, and blood pressure, height, weight, subscapular skinfolds, and fasting plasma glucose, insulin, and lipid profiles were assessed. Nutrient intakes were expressed as average density per 100 kcals i) from 9–24 months, and ii) at follow-up. Reduced rank regression (RRR) was used to identify the combination of nutrient intakes explaining the greatest variation in the outcome variables. Multiple linear regression models adjusting for subscapular skinfold-for-age Z-scores (SSFZ) were used to test whether observed relationships were mediated by body composition. Results Of the 153 children included, 26% were stunted at follow-up. RRR extracted 2 factors explaining 7% of the variation in infant nutrient intakes and 12% of the variation in response variables. The first factor had higher loadings for vitamin D, calcium, and cholesterol, while the second had higher loadings for non-animal source protein and iron. RRR also extracted 2 factors from the child intake data. These factors had higher loadings for sugar and fats, and sugar and protein, respectively. The first infant RRR factor was associated with lower plasma triglycerides and higher high-density lipoprotein, whereas the second was associated with higher homeostatic model assessment-insulin resistance (HOMA-IR) and weight-for-height Z-scores (WHZ). The first child RRR factor was associated with higher triglycerides, HOMA-IR, and WHZ, and the second was related to higher blood pressure. Associations with glucose and insulin, but not blood pressure or cholesterol, were attenuated after adjusting for SSFZ. Conclusions Nutrient densities of the diet in each childhood are associated with cardiometabolic profile in a chronically undernourished population. Funding Sources The project was supported by the Thrasher Foundation and the BMGF.

Objectives Over the short term, infants may grow in a ‘bimodal’ manner, with interspersed periods of greater and lesser growth. Our aim was to describe the modality of high-resolution growth dynamics of infants who experienced cumulative growth faltering in the first year of life. Methods Thrice-weekly measurements of length were recorded for n = 58 children enrolled from birth to one year in the Peru cohort of the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development’ (MAL-ED) study. Finite mixture models were fitted to the length velocity data to test for evidence of multiphasic patterns. We then tested whether evidence of a multiphasic pattern remained after applying a smoothing algorithm to account for measurement error. Data was smoothed using kernel regression with a monotonic constraint. Finite mixture models were fitted to unsmoothed and smoothed data to examine whether growth patterns varied by age and sex. We also fitted stratified models to compare short-term growth patterns between infants who maintained a consistent length-for-age Z-score (LAZ) from 2–12 months of age, versus those whose LAZ decreased by at least 0.25 over the same period. Results Unsmoothed data were best described by a biphasic finite mixture model. The growth of children less than 3 months old was described by a mixture of two normal distributions with both means significantly greater than zero (0.110 cm/day, 95%CI: 0.105, 0.114 and 0.291 cm/day, 95%CI: 0.235, 0.347). By 6 months, this transitioned to a pattern of two normal distributions, one with a mean near zero (0.019, 95% CI: 0.0178, 0.020), and one with a mean of 0.102 cm/day (95% CI: 0.098, 0.0107). Children who lost 0.25 or more in LAZ from 2 to 12 months had a similar mean growth velocity in both the ‘low’ and ‘high’ growth phase but spent smore time in the former phase (54.9% of days versus 39.2% of days) than children who either maintained or gained LAZ over the same age. Conclusions Consistent with other reports, we find that infant growth appears to follow bimodal dynamics characterized by intervals of greater velocities as well as periods of much lower growth. Funding Sources This work was supported by the National Institutes of Health and the BMGF.