Examining the Underlying Role of Environmental Enteric Dysfunction (EED) in Childhood Stunting and Recommending a Diagnostic Method to Improve Detection in Children Living in Developing Countries Open Access

Abstract

Background: Childhood stunting is a global health problem affecting children under the age of five years old living in low and middle-income countries (LMIC). The pathophysiology of childhood stunting has been poorly understood for many years and now new studies are suggesting that Environmental Enteric Dysfunction (EED), which impacts the structure and function of the small intestines, may be associated with stunting or failed linear growth. Presently, there is no specific and well-validated diagnostic or detection criteria available to identify and diagnosis EED in children.

Purpose: The purpose of this scoping review is to examine diagnostic testing modalities that are available to detect EED against criteria that includes: study design, social and political context of applying the diagnostic method in the target population, healthcare infrastructure in the community of the target population, cost, ethics, and scalability. The review concludes with a recommendation for the most suitable diagnostic test for children under the age of five years living in low resource settings with inadequate water supply, poor sanitation and hygiene services, high prevalence rates of infectious diseases, and poor healthcare system infrastructure.

Methods: Peer reviewed papers were generated from three databases based on search terms that included “environmental enteric dysfunction,” “clinical marker” and  “diagnosis”. Inclusion criteria included articles that were written in English and discussed a diagnostic or detection test that determined if a child under the age of five years old living in a LMIC, was at risk for developing EED or diagnosing a child with full-blown EED. Exclusion criteria included studies that discussed the association between EED and stunting without incorporating diagnostic methods.

Results: A total of 43 articles were identified for the scoping review after searching the three databases. Thirty-four articles were excluded from the review because they were duplicates; or they were not studies that discussed diagnostic methods for at risk children LMICs; or because they were articles that did not discuss diagnostic methods to detect EED. Nine articles were included in the scoping review. Diagnostic methods that were identified included biomarkers (fecal markers), lactulose mannitol (L:M) ratio, plasma tryptophan, bile acids, and optical biopsies.

Discussion and Recommendation: Based on the analysis of the nine articles against criteria, fecal mRNAs transcript testing could be utilized to determine if a child is at risk for developing EED or for diagnosing a child with full-blown EED. Although further research is needed to determine the validity and reliability of mRNA transcripts, it could serve as a promising non-invasive detection test to diagnose EED in children within low resource settings.

 

 

Table of Contents

Table of Contents

 

CHAPTER 1: BACKGROUND ............................................................................................1

SECTION 1.1: STUNTING ........................................................................................................ 1

SECTION 1.2: STUNTING & EED ............................................................................................12

SECTION 1.3: EED ...............................................................................................................12

SECTION 1.4: HISTORY OF EED..............................................................................................14

SECTION 1.5: DIAGNOSING EED ............................................................................................16

CHAPTER 2: RESEARCH QUESTION/PURPOSE OF THE REVIEW ............................. 18

CHAPTER 3: METHODS ....................................................................................................19

CHAPTER 4: RESULTS ......................................................................................................22

SECTION 4.1: STUDIES INCLUDED IN THE REVIEW..................................................................... 22

Subsection 4.1.a: Biomarkers & Fecal Markers ..................................................................23

Subsection 4.1.b: Lactulose Mannitol Ratio ........................................................................28

Subsection 4.1.c: Plasma Tryptophan ................................................................................29

Subsection 4.1.d: Bile Acids ...............................................................................................30

Subsection 4.1.c: Optical Biopsy ........................................................................................32

CHAPTER 5: DISCUSSION............................................................................................... 35

SECTION 5.1: STUDY DESIGN ................................................................................................ 35

SECTION 5.2: SOCIAL & POLITICAL CONTEXT ......................................................................... 36

SECTION 5.3: HEALTH CARE INFRASTRUCTURE ...................................................................... 37

SECTION 5.4: COST .............................................................................................................. 38

SECTION 5.5: ETHICS ........................................................................................................... 39

SECTION 5.6: SCALABILITY .................................................................................................... 40

SECTION 5.7: FUTURE DIRECTION ......................................................................................... 40

CHAPTER 6: RECOMMENDATION .................................................................................. 42

REFERENCES ................................................................................................................... 44

APPENDICES ......................................................................................................................48

APPENDIX 1 ............................................................................................................................48

APPENDIX 2 ........................................................................................................................... 49

APPENDIX 3 ............................................................................................................................54

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Environmental Health Health Sciences, Nutrition Health Sciences, Public Health
Keyword	Environmental Enteric Environmental Enteric Dysfunction Environmental Enteropathy Biomarker (environmental enteric OR "environmental enteric dysfunction" OR "environmental enteropathy") AND ('biological marker'/exp OR biomarker* OR clinical marker* OR biological marker*) AND (diagnosis OR diagnostic OR testing OR test OR causality OR etiology) Clinical Marker Biological Marker
Committee Chair / Thesis Advisor	McGriff, Joanne , Emory University
Partnering Agencies	Does not apply (no collaborating organization)

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