Volume 96, Issue 2
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Growth and development shortfalls that are disproportionately prevalent in children living in poor environmental conditions are postulated to result, at least in part, from abnormal gut function. Using data from The Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) longitudinal cohort study, we examine biomarkers of gut inflammation and permeability in relation to environmental exposures and feeding practices. Trends in the concentrations of three biomarkers, myeloperoxidase (MPO), neopterin (NEO), and α-1-antitrypsin (AAT), are described from fecal samples collected during the first 2 years of each child's life. A total of 22,846 stool samples were processed during the longitudinal sampling of 2,076 children 0–24 months of age. Linear mixed models were constructed to examine the relationship between biomarker concentrations and recent food intake, symptoms of illness, concurrent enteropathogen infection, and socioeconomic status. Average concentrations of MPO, NEO, and AAT were considerably higher than published references for healthy adults. The concentration of each biomarker tended to decrease over the first 2 years of life and was highly variable between samples from each individual child. Both MPO and AAT were significantly elevated by recent breast milk intake. All three biomarkers were associated with pathogen presence, although the strength and direction varied by pathogen. The interpretation of biomarker concentrations is subject to the context of their collection. Herein, we identify that common factors (age, breast milk, and enteric infection) influence the concentration of these biomarkers. Within the context of low- and middle-income communities, we observe concentrations that indicate gut abnormalities, but more appropriate reference standards are needed.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Korpe PS, Petri WA, Jr, 2012. Environmental enteropathy: critical implications of a poorly understood condition. Trends Mol Med 18: 328336.[Crossref] [Google Scholar]
  2. Prendergast A, Kelly P, , 2012. Enteropathies in the developing world: neglected effects on global health. Am J Trop Med Hyg 86: 756763.[Crossref] [Google Scholar]
  3. Keusch GT, Denno DM, Black RE, Duggan C, Guerrant RL, Lavery JV, Nataro JP, Rosenberg IH, Ryan ET, Tarr PI, Ward H, Bhutta ZA, Coovadia H, Lima A, Ramakrishna B, Zaidi AKM, Burgess DCH, Brewer T, , 2014. Environmental enteric dysfunction: pathogenesis, diagnosis, and clinical consequences. Clin Infect Dis 59 (Suppl 4): S207S212.[Crossref] [Google Scholar]
  4. Kosek M, Guerrant RL, Kang G, Bhutta Z, Yori PP, Gratz J, Gottlieb M, Lang D, Lee G, Haque R, Mason CJ, Ahmed T, Lima A, Petri WA, Houpt E, Olortegui MP, Seidman JC, Mduma E, Samie A, Babji S, , 2014. Assessment of environmental enteropathy in the MAL-ED cohort study: theoretical and analytic framework. Clin Infect Dis 59 (Suppl 4): S239S247.[Crossref] [Google Scholar]
  5. Sutherland AD, Gearry RB, Frizelle FA, , 2008. Review of fecal biomarkers in inflammatory bowel disease. Dis Colon Rectum 51: 12831291.[Crossref] [Google Scholar]
  6. MAL-ED Network Investigators. Causal pathways of environmental enteropathy: the MAL-ED multicenter birth cohort study. Lancet (In press). [Google Scholar]
  7. George CM, Oldja L, Biswas SK, Perin J, Lee GO, Ahmed S, Haque R, Sack RB, Parvin T, Azmi IJ, Bhuyian SI, Talukder KA, Faruque AG, , 2015. Fecal markers of environmental enteropathy are associated with animal exposure and caregiver hygiene in Bangladesh. Am J Trop Med Hyg 93: 269275.[Crossref] [Google Scholar]
  8. Kelly P, Menzies I, Crane R, Zulu I, Nickols C, Feakins R, Mwansa J, Mudenda V, Katubulushi M, Greenwald S, Farthing M, , 2004. Responses of small intestinal architecture and function over time to environmental factors in a tropical population. Am J Trop Med Hyg 70: 412419. [Google Scholar]
  9. Kosek M, Haque R, Lima A, Babji S, Shrestha S, Qureshi S, Amidou S, Mduma E, Lee G, Yori PP, Guerrant RL, Bhutta Z, Mason C, Kang G, Kabir M, Amour C, Bessong P, Turab A, Seidman J, Olortegui MP, Quetz J, Lang D, Gratz J, Miller M, Gottlieb M, , 2013. Fecal markers of intestinal inflammation and permeability associated with the subsequent acquisition of linear growth deficits in infants. Am J Trop Med Hyg 88: 390396.[Crossref] [Google Scholar]
  10. Naylor C, Lu M, Haque R, Mondal D, Buonomo E, Nayak U, Mychaleckyj JC, Kirkpatrick B, Colgate R, Carmolli M, Dickson D, van der Klis F, Weldon W, Steven Oberste M, Ma JZ, Petri WA, Jr, 2015. Environmental enteropathy, oral vaccine failure and growth faltering in infants in Bangladesh. EBioMedicine 2: 17591766.[Crossref] [Google Scholar]
  11. Field CJ, , 2005. The immunological components of human milk and their effect on immune development in infants. J Nutr 135: 14. [Google Scholar]
  12. Lönnerdal B, , 2010. Bioactive proteins in human milk: mechanisms of action. J Pediatr 156 (Suppl 2): S26S30.[Crossref] [Google Scholar]
  13. MAL-ED Network Investigators Acosta AM, Chavez CB, Flores JT, Olotegui MP, Pinedo SR, Trigoso DR, Vasquez AO, Ahmed I, Alam D, Ali A, Bhutta ZA, Qureshi S, Shakoor' S, Soofi S, Turab A, Yousafzai AK, Zaidi AKM, Bodhidatta L, Mason CJ, Babji S, Bose A, John S, Kang G, Kurien B, Muliyil J, Raghava MV, Ramachandran A, Rose A, Pan W, Ambikapathi R, Carreon D, Charu V, Dabo L, Doan V, Graham J, Hoest C, Knobler S, Lang D, McCormick B, McGrath M, Miller M, Mohale A, Nayyar G, Psaki S, Rasmussen Z, Richard S, Seidman J, Wang V, Blank R, Gottlieb M, Tountas K, Amour C, Mduma E, Ahmed T, Ahmed AMS, Dinesh M, Tofail F, Haque R, Hossain I, Islam M, Mahfuz M, Chandyo RK, Shrestha PS, Shrestha R, Ulak M, Black R, Caulfield L, Checkley W, Chen P, Kosek M, Lee G, Yori PP, Murray-Kolb L, Schaefer B, Pendergast L, Abreu C, Bindá A, Costa H, Moura AD, Filho JQ, Leite Á, Lima A, Lima N, Lima I, Maciel B, Moraes M, Mota F, Oria R, Quetz J, Soares A, Svensen E, Tor S, Patil C, Bessong P, Mahopo C, Mapula A, Nesamvuni C, Nyathi E, Samie A, Barrett L, Gratz J, Guerrant R, Houpt E, Olmsted L, Petri W, Platts-Mills J, Scharf R, Shrestha B, Shrestha SK, ; , 2014. The MAL-ED study: a multinational and multidisciplinary approach to understand the relationship between enteric pathogens, malnutrition, gut physiology, physical growth, cognitive development, and immune responses in infants and children up to 2 years of age in resource-poor environments. Clin Infect Dis 59 (Suppl 4): S193S206. [Google Scholar]
  14. Caulfield LE, Bose A, Chandyo RK, Nesamvuni C, de Moraes ML, Turab A, Patil C, Mahfuz M, Ambikapathi R, Ahmed T, , 2014. Infant feeding practices, dietary adequacy, and micronutrient status measures in the MAL-ED study. Clin Infect Dis 59 (Suppl 4): S248S254.[Crossref] [Google Scholar]
  15. Richard SA, Barrett LJ, Guerrant RL, Checkley W, Miller MA, , 2014. Disease surveillance methods used in the 8-site MAL-ED cohort study. Clin Infect Dis 59 (Suppl 4): S220S224.[Crossref] [Google Scholar]
  16. Houpt E, Gratz J, Kosek M, Zaidi AKM, Qureshi S, Kang G, Babji S, Mason C, Bodhidatta L, Samie A, Bessong P, Barrett L, Lima A, Havt A, Haque R, Mondal D, Taniuchi M, Stroup S, McGrath M, Lang D, The MAL-ED Network Investigators; , 2014. Microbiologic methods utilized in the MAL-ED cohort study. Clin Infect Dis 59 (Suppl 4): S225S232.[Crossref] [Google Scholar]
  17. Richard SA, McCormick BJJ, Miller MA, Caulfield LE, Checkley W, , 2014. Modeling environmental influences on child growth in the MAL-ED cohort study: opportunities and challenges. Clin Infect Dis 59 (Suppl 4): S255S260.[Crossref] [Google Scholar]
  18. Psaki SR, Seidman JC, Miller M, Gottlieb M, Bhutta ZA, Ahmed T, Ahmed AS, Bessong P, John SM, Kang G, Kosek M, Lima A, Shrestha P, Svensen E, Checkley W, MAL-ED Network Investigators; , 2014. Measuring socioeconomic status in multicountry studies: results from the eight-country MAL-ED study. Popul Health Metr 12: 8.[Crossref] [Google Scholar]
  19. Nakagawa S, Schielzeth H, , 2013. A general and simple method for obtaining R2 from generalized linear mixed-effects models. Methods Ecol Evol 4: 133142.[Crossref] [Google Scholar]
  20. Saiki T, , 1998. Myeloperoxidase concentrations in the stool as a new parameter of inflammatory bowel disease. Kurume Med J 45: 6973.[Crossref] [Google Scholar]
  21. Ledjeff E, Artner-Dworzak E, Witasek A, Fuchs D, Hausen A, , 2013. Neopterin concentrations in colon dialysate. Pteridines 12: 155160. [Google Scholar]
  22. Beckmann G, Rüffer A, , 2000. Mikroökologie des Darms: Grundlagen–Diagnostik–Therapie (vergriffen, keine Neuauflage). Hannover, Germany: Schlütersche Verlag. [Google Scholar]
  23. United Nations International Children's Emergency Fund, World Health Organization, 2006. Core Questions on Drinking Water and Sanitation for Household Surveys. New York, NY: World Health Organization. Available at: http://apps.who.int/iris/handle/10665/43489. Accessed May 3, 2016. [Google Scholar]
  24. van Elburg RM, Fetter WPF, Bunkers CM, Heymans HSA, , 2003. Intestinal permeability in relation to birth weight and gestational and postnatal age. Arch Dis Child Fetal Neonatal Ed 88: F52F55.[Crossref] [Google Scholar]
  25. Shulman RJ, Schanler RJ, Lau C, Heitkemper M, Ou CN, Smith EO, , 1998. Early feeding, antenatal glucocorticoids, and human milk decrease intestinal permeability in preterm infants. Pediatr Res 44: 519523.[Crossref] [Google Scholar]
  26. Battersby AJ, Gibbons DL, , 2013. The gut mucosal immune system in the neonatal period. Pediatr Allergy Immunol 24: 414421.[Crossref] [Google Scholar]
  27. Groer MW, Luciano AA, Dishaw LJ, Ashmeade TL, Miller E, Gilbert JA, , 2014. Development of the preterm infant gut microbiome: a research priority. Microbiome 2: 38.[Crossref] [Google Scholar]
  28. Sela DA, Mills DA, , 2010. Nursing our microbiota: molecular linkages between bifidobacteria and milk oligosaccharides. Trends Microbiol 18: 298307.[Crossref] [Google Scholar]
  29. Chowanadisai W, Lönnerdal B, , 2002. Alpha(1)-antitrypsin and antichymotrypsin in human milk: origin, concentrations, and stability. Am J Clin Nutr 76: 828833. [Google Scholar]
  30. Matsubara Y, Gaull GE, , 1985. Biopterin and neopterin in various milks and infant formulas. Am J Clin Nutr 41: 110112. [Google Scholar]
  31. World Health Organization, 1998. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva, Switzerland: World Health Organization. Available at: http://www.who.int/nutrition/publications/infantfeeding/WHO_NUT_98.1/en/. Accessed May 14, 2015. [Google Scholar]
  32. Tsopmo A, Diehl-Jones BW, Aluko RE, Kitts DD, Elisia I, Friel JK, , 2009. Tryptophan released from mother's milk has antioxidant properties. Pediatr Res 66: 614618.[Crossref] [Google Scholar]
  33. Elisia I, Tsopmo A, Friel JK, Diehl-Jones W, Kitts DD, , 2011. Tryptophan from human milk induces oxidative stress and upregulates the Nrf-2-mediated stress response in human intestinal cell lines. J Nutr 141: 14171423.[Crossref] [Google Scholar]
  34. Davidson LA, Lönnerdal B, , 1990. Fecal alpha 1-antitrypsin in breast-fed infants is derived from human milk and is not indicative of enteric protein loss. Acta Paediatr Scand 79: 137141.[Crossref] [Google Scholar]
  35. Richard SA, Black RE, Gilman RH, Guerrant RL, Kang G, Lanata CF, Mølbak K, Rasmussen ZA, Sack RB, Valentiner-Branth P, Checkley W, Childhood Malnutrition and Infection Network; , 2014. Catch-up growth occurs after diarrhea in early childhood. J Nutr 144: 965971.[Crossref] [Google Scholar]
  36. MAL-ED Network Investigators. Enteric pathogens and dietary intakes, but not diarrhoea, affect growth velocity and attained size at 24 months: the MAL-ED multicenter birth cohort study. Lancet (In press). [Google Scholar]
  37. Lee GO, McCormick BJJ, Seidman JC, Kosek MN, Haque R, Ahmed T, Olortegui MP, Yori PP, Lima AAM, Quetz J, Qureshi S, Bhutta ZA, Babji S, Kang G, Samie A, Bessong PO, Amour C, Mduma E, Shrestha SK, Mason CJ, Ambikapathi R, Lang DR, Gottlieb M, Guerrant RL, Caulfield LE, . Factors associated with gut permeability over time as assessed by the lactulose: mannitol test in the eight-site MAL-ED birth cohort study. Pediatr J Gastroenterol Nutr (In press). [Google Scholar]
  38. Menzies IS, Zuckerman MJ, Nukajam WS, Somasundaram SG, Murphy B, Jenkins AP, Crane RS, Gregory GG, , 1999. Geography of intestinal permeability and absorption. Gut 44: 483489.[Crossref] [Google Scholar]
  39. Prata M de MG, Havt A, Bolick D, Pinkerton R, Lima AAM, Guerrant RL, , 2016. Comparisons between myeloperoxidase, lactoferrin, calprotectin and lipocalin-2, as fecal biomarkers of intestinal inflammation in malnourished children. J Transl Sci 2: 134139. [Google Scholar]

Data & Media loading...

Supplementary PDF

  • Received : 17 Jun 2016
  • Accepted : 06 Sep 2016
  • Published online : 08 Feb 2017

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error