title: Small Intestine Bacterial Overgrowth and Environmental Enteropathy in Bangladeshi Children.
abstract: Recent studies suggest small intestine bacterial overgrowth (SIBO) is common among developing world children. SIBO's pathogenesis and effect in the developing world are unclear. Our objective was to determine the prevalence of SIBO in Bangladeshi children and its association with malnutrition. Secondary objectives included determination of SIBO's association with sanitation, diarrheal disease, and environmental enteropathy. We performed a cross-sectional analysis of 90 Bangladeshi 2-year-olds monitored since birth from an impoverished neighborhood. SIBO was diagnosed via glucose hydrogen breath testing, with a cutoff of a 12-ppm increase over baseline used for SIBO positivity. Multivariable logistic regression was performed to investigate SIBO predictors. Differences in concomitant inflammation and permeability between SIBO-positive and -negative children were compared with multiple comparison adjustment. A total of 16.7% (15/90) of the children had SIBO. The strongest predictors of SIBO were decreased length-for-age Z score since birth (odds ratio [OR], 0.13; 95% confidence interval [CI], 0.03 to 0.60) and an open sewer outside the home (OR, 4.78; 95% CI, 1.06 to 21.62). Recent or frequent diarrheal disease did not predict SIBO. The markers of intestinal inflammation fecal Reg 1β (116.8 versus 65.6 µg/ml; P = 0.02) and fecal calprotectin (1,834.6 versus 766.7 µg/g; P = 0.004) were elevated in SIBO-positive children. Measures of intestinal permeability and systemic inflammation did not differ between the groups. These findings suggest linear growth faltering and poor sanitation are associated with SIBO independently of recent or frequent diarrheal disease. SIBO is associated with intestinal inflammation but not increased permeability or systemic inflammation.
  
  
  OBJECTIVE
  A total of 165 million children worldwide are considered stunted, which is associated with increased risk of death prior to age 5 years and cognitive disability. Stunting has, in part, been attributed to the presence of environmental enteropathy. Environmental enteropathy is a poorly understood condition leading to chronic intestinal inflammation. It has been postulated that small intestine bacterial overgrowth contributes to the pathogenesis of environmental enteropathy as overgrowth has been associated with intestinal inflammation and micronutrient malabsorption when it develops in other clinical contexts. This study confirms the finding that overgrowth occurs at high rates in the developing world. This is the first study to show that overgrowth is associated with intestinal inflammation and linear growth delay in this setting and is the first to examine why children with no known gastrointestinal dysfunction develop overgrowth from the developing world environment.
authors.affiliation: Division of Pediatric Infectious Diseases, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, USA wap3g@virginia.edu jeffrey.donowitz@vcuhealth.org.
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Donowitz
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Rashidul
authors.initials: R
authors.lastname: Haque
authors.affiliation: Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont, USA.
authors.forename: Beth D
authors.initials: BD
authors.lastname: Kirkpatrick
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Masud
authors.initials: M
authors.lastname: Alam
authors.affiliation: Department of Statistics, University of Virginia, Charlottesville, Virginia, USA.
authors.forename: Miao
authors.initials: M
authors.lastname: Lu
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Mamun
authors.initials: M
authors.lastname: Kabir
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Shahria Hafiz
authors.initials: SH
authors.lastname: Kakon
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Bushra Zarin
authors.initials: BZ
authors.lastname: Islam
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Sajia
authors.initials: S
authors.lastname: Afreen
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Abu
authors.initials: A
authors.lastname: Musa
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Shaila Sharmeen
authors.initials: SS
authors.lastname: Khan
authors.affiliation: Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont, USA.
authors.forename: E Ross
authors.initials: ER
authors.lastname: Colgate
authors.affiliation: Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont, USA.
authors.forename: Marya P
authors.initials: MP
authors.lastname: Carmolli
authors.affiliation: Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA.
authors.forename: Jennie Z
authors.initials: JZ
authors.lastname: Ma
authors.affiliation: Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA wap3g@virginia.edu jeffrey.donowitz@vcuhealth.org.
authors.forename: William A
authors.initials: WA
authors.lastname: Petri
mesh_terms: D001459:Bangladesh / Q000453:epidemiology; D001765:Blind Loop Syndrome / Q000453:epidemiology* / Q000473:pathology*; D002648:Child; D003430:Cross-Sectional Studies; D004781:Environmental Exposure; D005243:Feces / Q000737:chemistry; D006801:Humans; D007421:Intestine, Small / Q000473:pathology*; D039841:Leukocyte L1 Antigen Complex / Q000032:analysis; D051847:Lithostathine / Q000032:analysis; D044342:Malnutrition / Q000150:complications*; D011203:Poverty; D015995:Prevalence; D012307:Risk Factors
chemical_list: D039841:Leukocyte L1 Antigen Complex; D051847:Lithostathine; C497618:REG1B protein, human