title: Prolonged episodes of acute diarrhea reduce growth and increase risk of persistent diarrhea in children.
abstract: OBJECTIVE
  Prolonged episodes of acute diarrhea (ProD; duration 7-13 days) or persistent diarrhea (PD; duration ≥14 days) are important causes of undernutrition, yet the epidemiology and nutritional impact of ProD are poorly understood.
  
  
  METHODS
  We conducted a 10-year cohort study of 414 children from a Brazilian shantytown who were followed from birth; data were collected on diarrhea, enteric pathogens, and anthropometry.
  
  
  RESULTS
  During 1276 child-years of observation, we recorded 3257 diarrheal episodes. ProD was twice as common as PD (12% and 5% of episodes, respectively); ProD and PD together accounted for 50% of all days with diarrhea. ProD was more common in infants whose mothers had not completed primary school (relative risk [RR], 2.1; 95% confidence interval: 1.02-2.78). Early weaning was associated with earlier onset of ProD (Spearman ρ = 0.309; P = .005). Infants with ProD were twice as likely to develop PD in later childhood (log rank, P = .002) compared with infants with only acute diarrhea (AD; duration <7 days), even after controlling for confounders. Children's growth was more severely stunted before their first episode of ProD, compared with AD (mean height-for-age Z score (HAZ) -0.81 vs -0.51, respectively, P < .05, unpaired t test). Following ProD, HAZ (ΔHAZ = -0.232) and weight-for-age (ΔWAZ = -0.26) significantly decreased (P < .005 in paired t tests). ProD was associated with Cryptosporidium and Shigella infections.
  
  
  CONCLUSIONS
  ProD accounts for significant morbidity and identifies children at risk of a vicious cycle of diarrhea and malnutrition. Further studies are needed to address the recognition and control of ProD and its consequences in resource-limited settings and assess its role in PD pathogenesis.
authors.affiliation: Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA. sean.moore@cchmc.org
authors.forename: Sean R
authors.initials: SR
authors.lastname: Moore
authors.forename: Noélia L
authors.initials: NL
authors.lastname: Lima
authors.forename: Alberto M
authors.initials: AM
authors.lastname: Soares
authors.forename: Reinaldo B
authors.initials: RB
authors.lastname: Oriá
authors.forename: Relana C
authors.initials: RC
authors.lastname: Pinkerton
authors.forename: Leah J
authors.initials: LJ
authors.lastname: Barrett
authors.forename: Richard L
authors.initials: RL
authors.lastname: Guerrant
authors.forename: Aldo A M
authors.initials: AA
authors.lastname: Lima
mesh_terms: D000208:Acute Disease; D001196:Ascariasis / Q000150:complications; D001942:Breast Feeding; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003967:Diarrhea / Q000209:etiology*; D005260:Female; D006130:Growth Disorders / Q000209:etiology*; D006801:Humans; D007223:Infant; D008297:Male; D044342:Malnutrition / Q000209:etiology; D016016:Proportional Hazards Models; D012306:Risk; D012307:Risk Factors