Poor intestinal permeability in mildly stunted Nepali children: associations with weaning practices and Giardia lamblia infection

Abstract

Studies in the Gambia, using the lactulose–mannitol dual-sugar intestinal permeability test (lactulose:mannitol ratio) as a non-invasive way of investigating mucosal damage, have shown that food malabsorption is significantly associated with early growth retardation. In this cross-sectional study, 210 poor urban Nepali children, 0–60 months old, were recruited and measured for height or length and weight, 167 were examined for intestinal permeability and 173 for parasite infection. Weaning and morbidity data were collected from 172 caretakers. Children were mildly stunted (mean height-for-age Z-score −1·45) and underweight (mean weight-for-age Z-score −1·62). The lactulose:mannitol ratio (0·26) was poorer than that of UK children (0·12), but similar to that found in Bengali children of the same age (0·24). Two stages of weaning, the onset supplementary feeding (6 months) and the cessation of breast-feeding (23 months), were shown to have differential impact. In children currently breast-feeding, the duration of supplementation was negatively related to lactose (P<0·001) and lactose:lactulose values (P<0·0001), indicating lactose maldigestion. In children who had ceased breast-feeding, a longer period of lactation was associated with poorer intestinal permeability (P=0·031), and poorer height-for-age (P=0·024), which was an unexpected result. No significant relationships were found between intestinal permeability and growth, or with morbidity and helminth infection, except in children withGiardia lambliawho had worse lactulose:mannitol ratios than those without (0·43v.0·25 respectively,P=0·014). It is likely that insults to the gut (e.g. Giardia) and challenges to the immune system (weaning) have a different impact in early and late infancy.

An evaluation of an operations research project to reduce childhood stunting in a food-insecure area in Ethiopia

“…These studies highlight that improved child growth is not only a food security issue but is also closely related to water, sanitation and hygiene. There is some evidence that tropical enteropathy (abnormalities of small bowel structure and function associated with malabsorption) is elevated in stunted children (20) and is associated with chronic exposure to a variety of food-or water-borne micro-organisms, viruses, bacteria and protozoans (21) . A letter published in the Lancet discusses the evidence of the effect of poor sanitation and hygiene on linear growth and suggests substantial under-reporting of undernutrition due to the fact that an important causal pathway to malnutrition from poor hygiene and sanitation may be caused by tropical enteropathy and not just diarrhoea (22) .…”

Persistent G. lamblia impairs growth in a murine malnutrition model

“…al. demonstrated a relationship between G. lamblia during early childhood and gut dysfunction (24), suggesting the potential for intestinal pathology concomitant with infection. Conversely, the presence of G. lamblia in children has been associated with an increased time to the first episode of any diarrheal event, an effect that was eliminated after multinutrient supplementation (18).…”

Growth retardation and stunting of children in developing countries

“…A single layer of cells, the enterocytes, which line the mucosa, must be able to absorb nutrients, but must also act as a barrier to prevent environmental toxins and micro-organisms from gaining access to the body. Clearly, environmentally induced damage to the mucosa could compromise both nutrient uptake and barrier function, both of which could lead to impaired growth (Lunn, 2000), and this is the focus of the current paper by Goto et al (2002).…”

“…The paper by Goto et al (2002) in the present issue of the British Journal of Nutrition describes an investigation in which small intestinal mucosal function and integrity was assessed using the dual-sugar intestinal permeability test. The test is non-invasive and, as demonstrated in the study, can be used under field conditions.…”