What are Normal Defecation Patterns in Healthy Children up to Four Years of Age? A Systematic Review and Meta-Analysis.

OBJECTIVE: To summarize available data on defecation frequency and stool consistency of healthy children up to age 4 in order to estimate normal references values. STUDY DESIGN: Systematic review including cross-sectional, observational, and interventional studies published in English, that reported on defecation frequency and/or stool consistency in healthy children 0-4 years old. RESULTS: Seventy-five studies were included with 16 393 children and 40 033 measurements of defecation frequency and/or stool consistency. Based on visual inspection of defecation frequency data, a differentiation was made between two age categories: young infants (0-14 weeks old) and young children (15 weeks-4 years old). Young infants had a mean defecation frequency of 21.8 per week (95 % CI, 3.9-35.2) compared with 10.9 (CI, 5.7-16.7) in young children (P < .001). Among young infants, human milk-fed (HMF) infants had the highest mean defecation frequency per week (23.2 [CI, 8.8-38.1]), followed by formula-fed (FF) infants (13.7 [CI 5.4-23.9]), and mixed-fed (MF) infants (20.7 [CI, 7.0-30.2]). Hard stools were infrequently reported in young infants (1.5%) compared with young children (10.5%), and a reduction in the frequency of soft/watery stools was observed with higher age (27.0% in young infants compared with 6.2% in young children). HMF young infants had softer stools compared with FF young infants. CONCLUSIONS: Young infants (0-14 weeks old) have softer and more frequent stools compared with young children (15 weeks-4 years old).

Nonpharmacologic Treatment for Children with Functional Constipation: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the effectiveness and safety of nonpharmacologic interventions for the treatment of childhood functional constipation. STUDY DESIGN: Randomized controlled trials (RCTs) evaluating nonpharmacologic treatments in children with functional constipation which reported at least 1 outcome of the core outcome set for children with functional constipation. RESULTS: We included 52 RCTs with 4668 children, aged between 2 weeks and 18 years, of whom 47% were females. Studied interventions included gut microbiome-directed interventions, other dietary interventions, oral supplements, pelvic floor-directed interventions, electrical stimulation, dry cupping, and massage therapy. An overall high risk of bias was found across the majority of studies. Meta-analyses for treatment success and/or defecation frequency, including 20 RCTs, showed abdominal electrical stimulation (n = 3), Cassia Fistula emulsion (n = 2), and a cow's milk exclusion diet (n = 2 in a subpopulation with constipation as a possible manifestation of cow's milk allergy) may be effective. Evidence from RCTs not included in the meta-analyses, indicated that some prebiotic and fiber mixtures, Chinese herbal medicine (Xiao'er Biantong granules), and abdominal massage are promising therapies. In contrast, studies showed no benefit for the use of probiotics, synbiotics, an increase in water intake, dry cupping, or additional biofeedback or behavioral therapy. We found no RCTs on physical movement or acupuncture. CONCLUSIONS: More well-designed high quality RCTs concerning nonpharmacologic treatments for children with functional constipation are needed before changes in current guidelines are indicated.

Transanal Irrigation in Children: Treatment Success, Quality of Life, Adherence, Patient Experience, and Independence.

OBJECTIVES: To investigate the clinical effectiveness and patient experience of transanal irrigation (TAI) in children with constipation or fecal incontinence. METHODS: Combined retrospective and cross-sectional study including pediatric patients who used a Navina TAI system. We retrospectively collected baseline characteristics and data on treatment success at 1- and 6-month follow-up (FU). Treatment success was defined as defecating at least 3 times per week and having less than 1 episode of fecal incontinence per week. We cross-sectionally assessed health-related quality of life (HRQoL), treatment adherence, treatment satisfaction (Treatment Satisfaction Questionnaire for Medication [TSQM]), illness perceptions, medication beliefs, and patient empowerment with validated questionnaires. RESULTS: Thirty-four patients were included (median age at start TAI: 11 years old [range, 6-18]), 32 in the retrospective review, and 26 in the cross-sectional survey (median of 3 years after initiation). Most patients were diagnosed with functional constipation (n = 26; 76%) or a neurogenic bowel disorder (n = 6; 18%). Treatment success rates significantly improved at each FU compared with baseline (baseline: 4/25 [16%]; 1-month FU: 12/16 [75%], P = 0.008; 6-month FU: 11/18 [61%], P = 0.016; cross-sectional FU: 13/26 [50%], P = 0.008). HRQoL scores were high (PedsQL median, 73 [IQR, 54-85]). Adherence (defined as Medication Adherence Report Scale [MARS] ≥ 23) was low (36%), whereas TSQM effectiveness scores were high (median, 69 [IQR, 47-86]). The majority of children (61%) reported an increase in independence since TAI treatment. Patient empowerment (GYPES) levels were similar to those reported in children with other chronic conditions. CONCLUSIONS: TAI with a Navina system is an effective bowel management system for children with intractable constipation or fecal incontinence.

Social environmental impact of COVID-19 and erectile dysfunction: an explorative review.

BACKGROUND: To date, no attempt has been made to collate literature on the relationship between the social environmental impact of COVID-19 and erectile dysfunction. The aim of this explorative review was to assess and compare the prevalence of erectile dysfunction (ED) in male healthcare workers and males during the COVID-19 pandemic. METHODS: A systematic review of major databases from inception to February 2021 was conducted. Prevalence data were extracted, and a random-effects meta-analysis was undertaken. OUTCOMES: The pooled prevalence of ED amongst healthcare workers working in COVID-19 specific environments, and non-healthcare during the COVID-19 pandemic. RESULTS: Of 52 initial studies, six were included for the final analysis. The pooled prevalence of ED in healthcare workers working in a COVID-19 environment was 63.6% (95% CI 20.3-92.3%), and in non-healthcare workers during the COVID-19 pandemic was 31.9% (95% CI 19.5-47.6%). CONCLUSION: The prevalence of ED in healthcare workers working in COVID-19 environments was higher than representative samples and is of concern. Sexual health (and by extension, overall health), should be a priority when considering ways to care for this population. Considering the social environmental impact of COVID-19 on sexual health and in particular on ED, it is important to provide adequate psychological support systems and to promote quality of life with particular attention to sexual health.

The Modified Bristol Stool Form Scale: A Reliable and Valid Tool to Score Stool Consistency in Dutch (Non)Toilet-trained Toddlers.

OBJECTIVE: The aim of the study was to assess whether the modified Bristol Stool Form Scale (m-BSFS) is reliable, valid and user-friendly to use by parents, grandparents, and day childcare employees to evaluate stool consistency in toilet and nontoilet-trained toddlers in the Netherlands. STUDY DESIGN: Translation to Dutch and validity of the m-BSFS (scoring 32 general stool pictures) for 1 to 3 year old toddlers (n = 89) was evaluated by parents, grandparents, and day childcare employees. A subgroup of participants scored an additional 7 pictures of stools in a diaper to validate the m-BSFS for non-toilet-trained toddlers (n = 16). To determine inter-rater reliability, 2-way random effects single-rater intraclass correlation coefficient (ICC)consistency was used. Intra-rater reliability was measured by Cohen kappa (κ) by rating the same pictures in random order twice, with at least 1 week between the first and second scoring. RESULTS: Inter- and intra-rater reliability of the m-BSFS were above recommended minimal standards of 0.61 for the 32 general stool pictures as well as for the 7 pictures of stools in a diaper. ICCconsistency for the general stool pictures of the first and second ratings were 0.71 (n = 89) and 0.79 (n = 77), respectively, with a κ of 0.71 (n = 77). ICCconsistency for the stools in diaper pictures of the first and second ratings were 0.93 (n = 16) and 0.93 (n = 15), respectively, with a κ of 0.77 (n = 15). CONCLUSIONS: The m-BSFS is reliable, valid and user-friendly to use by Dutch-speaking parents, grandparents, and day childcare workers to evaluate stool consistency in both toilet- and nontoilet-trained toddlers in the Netherlands.

Postbiotics and Their Potential Applications in Early Life Nutrition and Beyond.

Postbiotics are functional bioactive compounds, generated in a matrix during fermentation, which may be used to promote health. The term postbiotics can be regarded as an umbrella term for all synonyms and related terms of these microbial fermentation components. Therefore, postbiotics can include many different constituents including metabolites, short-chain fatty acids (SCFAs), microbial cell fractions, functional proteins, extracellular polysaccharides (EPS), cell lysates, teichoic acid, peptidoglycan-derived muropeptides and pili-type structures. Postbiotics is also a rather new term in the '-biotics' field. Where consensus exists for the definitions of pre- and probiotics, this is not yet the case for postbiotics. Here we propose a working definition and review currently known postbiotic compounds, their proposed mechanisms, clinical evidence and potential applications. Research to date indicates that postbiotics can have direct immunomodulatory and clinically relevant effects and evidence can be found for the use of postbiotics in healthy individuals to improve overall health and to relief symptoms in a range of diseases such as infant colic and in adults atopic dermatitis and different causes of diarrhea.

Effectiveness of Probiotics in Children With Functional Abdominal Pain Disorders and Functional Constipation: A Systematic Review.

OBJECTIVE: The objective of this study was to investigate the effect of probiotics on functional abdominal pain disorders (FAPD) and functional constipation (FC). METHODS: A systematic review was conducted, searching PubMed and Cochrane databases from inception to January 2018 for randomized controlled trials (RCTs) investigating the efficacy of probiotics in children aged 4 to 18 years with FAPD or children aged 0 to 18 years with FC. RESULTS: A total of 657 citations were identified. Finally, 11 RCTs for FAPD and 6 RCTs for FC were included. Some evidence exists for Lactobacillus rhamnosus GG (n=3) in reducing frequency and intensity of abdominal pain in children with irritable bowel syndrome. There is no evidence to recommend L. reuteri DSM 17938 (n=5), a mix of Bifidobacterium infantis, Bifidobacterium breve and Bifidobacterium longum (n=1), Bifidobacterium lactis (n=1) or VSL#3 (n=1) for children with FAPD. No evidence exists to support the use of Lactobacillus casei rhamnosus LCR35 (n=1), B. lactis DN173 010 (n=1), B. longum (n=1), L. reuteri DSM 17938 (n=1), a mix of B. infantis, B. breve and B. longum (n=1), or Protexin mix (n=1) for children with FC. In general, studies had an unclear or high risk of bias. CONCLUSIONS: Insufficient evidence exists for the use of probiotics in FAPD and FC, only L. rhamnosus GG seems to reduce frequency and intensity of abdominal pain but only in children with irritable bowel syndrome. A better understanding of differences in gut microbiota in health and disease might lead to better probiotic strategies to treat disease.

The LTAR Common Experiment at Upper Chesapeake Bay: Integrated.

Corn (Zea mays) crops harvested as grain in autumn do not provide opportunity for cover crop establishment, which may be remedied by interseeding cover crops into growing corn. Grazing cover crops after corn grain harvest could provide added revenues and increase nutrient cycling in the system while providing additional ecosystem services. However, tradeoffs between cash crop productivity and cover crop inclusion, and use as grazed forage, are not fully understood. This 4-year Long-Term Agroecosystem Research Integrated Common Experiment project evaluated the effect of interseeding cereal rye (Secale cereale) into corn for grazing after corn grain harvest on corn grain yield and late-season grazing. Cereal rye was interseeded into corn in early June. After corn grain harvest, six paddocks at each location were randomly allotted to grazed (GRAZ) or not grazed (NG). The GRAZ paddocks were grazed with beef cattle in late autumn and again in early spring if regrowth allowed. Paddocks were flown with an unmanned aerial system (UAS) to characterize spatial forage yield and quality. Cereal rye provided an additional 20-30 grazing days in the autumn for 24 beef cows on 4.8 ha. Early spring growth shows potential to provide even greater forage yields than autumn, but growth is less dependable. Corn grain yields did not decrease except in 2019 (dry year) when yields were 40% lower. There were no significant differences in soil health indicators between GRAZ and NG paddocks. The UAS shows promise as a tool for monitoring forage yield and quality and optimizing grazing management.

Effect of prebiotic oligosaccharides on bowel habit and the gut microbiota in children with functional constipation (Inside study): study protocol for a randomised, placebo-controlled, multi-centre trial.

BACKGROUND: Functional constipation (FC) in children is a common gastrointestinal disorder with a worldwide-pooled prevalence of 9.5%. Complaints include infrequent bowel movements, painful defecation due to hard and/or large stools, faecal incontinence, and abdominal pain. Prebiotic oligosaccharides have been shown to relieve constipation symptoms in young adults and elderly. However, sufficient evidence is lacking linking additional prebiotic intake to improve symptoms in children with FC. We hypothesise that prebiotic oligosaccharides are able to relieve symptoms of constipation in young children as well. METHODS: In the present randomised, double-blind, placebo-controlled, multi-centre study, we will study the effects of two prebiotic oligosaccharides in comparison to placebo on constipation symptoms in children of 1-5 years (12 to 72 months) of age diagnosed with FC according to the Rome IV criteria for functional gastrointestinal disorders. The primary outcome measure will be change in stool consistency. Secondary outcomes include stool frequency and stool consistency in a number of cases (%). Tertiary outcomes include among others painful defecation, use of rescue medication, and quality of life. In addition, the impact on gut microbiome outcomes such as faecal microbiota composition and metabolites will be investigated. Participants start with a run-in period, after which they will receive supplements delivered in tins with scoops for 8 weeks, containing one of the two prebiotic oligosaccharides or placebo, followed by a 4-week wash-out period. DISCUSSION: This randomised double-blind, placebo-controlled multi-centre study will investigate the effectiveness of prebiotic oligosaccharides in children aged 1-5 years with FC. TRIAL REGISTRATION: ClinicalTrials.gov NCT04282551. Registered on 24 February 2020.

Extensive embryonic patterning without cellular differentiation primes the plant epidermis for efficient post-embryonic stomatal activities.

Plant leaves feature epidermal stomata that are organized in stereotyped patterns. How does the pattern originate? We provide transcriptomic, imaging, and genetic evidence that Arabidopsis embryos engage known stomatal fate and patterning factors to create regularly spaced stomatal precursor cells. Analysis of embryos from 36 plant species indicates that this trait is widespread among angiosperms. Embryonic stomatal patterning in Arabidopsis is established in three stages: first, broad SPEECHLESS (SPCH) expression; second, coalescence of SPCH and its targets into discrete domains; and third, one round of asymmetric division to create stomatal precursors. Lineage progression is then halted until after germination. We show that the embryonic stomatal pattern enables fast stomatal differentiation and photosynthetic activity upon germination, but it also guides the formation of additional stomata as the leaf expands. In addition, key stomatal regulators are prevented from driving the fate transitions they can induce after germination, identifying stage-specific layers of regulation that control lineage progression during embryogenesis.

Investigation of the inorganic and organic phosphorus forms in animal manure.

The most viable way to beneficially use animal manure on most farms is land application. Over the past few decades, repeated manure application has shown adverse effects on environmental quality due to phosphorus (P) runoff with rainwater, leading to eutrophication of aquatic ecosystems. Improved understanding of manure P chemistry may reduce this risk. In this research, 42 manure samples from seven animal species (beef and dairy cattle, swine, chicken, turkey, dairy goat, horse, and sheep) were sequentially fractionated with water, NaHCO3, NaOH, and HCl. Inorganic (P(i)), organic (P(o)), enzymatic hydrolyzable (P(e); monoester-, DNA-, and phytate-like P), and nonhydrolyzable P were measured in each fraction. Total dry ash P (P(t)) was measured in all manures. Total fractionated P (P(ft)) and total P(i) (P(it)) showed a strong linear relationship with P(t). However, the ratios between P(ft)/P(t) and P(it)/P(t) varied from 59 to 117% and from 28 to 96%, respectively. Water and NaHCO3 extracted most of the P(i) in manure from ruminant+horse, whereas in nonruminant species a large fraction of manure P was extracted in the HCl fraction. Manure P(e) summed over all fractions (P(et)) accounted for 41 to 69% of total P(0) and 4 to 29% of P(t). The hydrolyzable pool in the majority of the manures was dominated by phytate- and DNA-like P in water, monoester- and DNA-like P in NaHCO3, and monoester- and phytate-like P in NaOH and HCl fractions. In conclusion, if one assumes that the P(et) and P(it) from the fractionation can become bioavailable, then from 34 to 100% of P(t) in animal manure would be bioavailable. This suggests the need for frequent monitoring of manure P for better manure management practices.

Manure composition and incorporation effects on phosphorus in runoff following corn biomass removal.

Greater demand for corn ( L.) stover for bioenergy use may lead to increased corn production acreage with minimal surface residue cover, resulting in greater risk for soil erosion and phosphorus (P) losses in runoff. A rainfall simulation study was conducted to determine the effects of spring-applied dairy cow () manure (none, in-barn composted, and exterior walled-enclosure pit) with >200 g kg organic solids content following fall corn biomass removal with and without incorporation (chisel plow [CP] and no-till [NT]) on sediment and P in runoff. Runoff was collected from a 0.83-m area for 60 min following the onset of rainfall simulation (76 mm h), once in spring and once in fall. Runoff dissolved reactive P (DRP) and dissolved organic P (DOP) concentrations were positively correlated with manure P rate and were higher in NT compared with CP. Conversely, sediment and particulate P (PP) concentrations in runoff were inversely correlated with manure P rate (and manure solids) and were higher in CP compared with NT. Runoff volume where no manure was applied was higher in NT than in CP in spring but similar in fall. The addition of manure reduced runoff volumes by an average of 82% in NT and 42% in CP over spring and fall. Results from this study indicate that surface application of dairy manure with relatively high solids content may reduce sediment and PP losses in runoff without increasing the risk of increased DRP and DOP losses in the year of application where corn biomass is harvested.

The effect of fiber and prebiotics on children's gastrointestinal disorders and microbiome.

INTRODUCTION: The bacteria received upon birth are the start of colonization of the approximately 1014 bacteria that are present in the mature human gastrointestinal tract, better known as the microbiota. The gut microbiota is implicated in gastrointestinal health, nutrient metabolism and benefits such as prevention of infection. Dietary fiber, including prebiotics, escape digestion in the small intestine and reach the colon intact, where they are partially or completely fermented by the gut microbiota. Areas covered: The possible interactions between dietary fiber, prebiotics and microbiota are discussed as well as how this relates to functional gastrointestinal disorders. During the first years of life the microbiota have not yet reached a stable state and is sensitive to disturbance by environmental factors. An imbalance in the microbiota early in life is found to be associated with several functional gastrointestinal disorders such as colic, functional abdominal pain, irritable bowel syndrome and constipation. Expert commentary: A better understanding of how gut microbial changes in early-life can impact gastrointestinal health might lead to new treatments or disease prevention. Nutritional strategies with fiber or prebiotics may support health due to modification of colonic microbiota composition and metabolic activity, for example by growth stimulation of Bifidobacterium and Lactobacillus.

Sorption of inorganic and total phosphorus from dairy and swine slurries to soil.

Understanding P sorption from animal manures is essential to formulate best management practices with regard to land application of manure from the standpoint of crop production and environmental quality. Little research has focused on the construction of P sorption isotherms where the P source is manure. The objectives of this study were to: (i) develop a procedure to characterize how inorganic P (P(i)) and total P (P(t)) from dairy slurry and swine slurry sorbs to soil; and (ii) compare the sorption characteristics of P(i) and P(t) where the P source was dairy slurry, swine slurry, or potassium phosphate (KH2PO4). Sorption solutions were prepared in 0.1 M KCl at pH 6 and equilibrated with soils at a 1:25 (w/v) soil/solution ratio for 24 h. Inorganic P, P(t), Al, and Fe in the equilibrated solutions were measured. For all soils, P(i) and P(t) sorption capacity of dairy slurry was greater than KH2PO4. Total P sorption capacity of swine slurry was greater than KH2PO4, while P(i) sorption capacity was less than KH2PO4. Overall, P(i) and P(t) sorption strengths of the manure slurries were less than or equal to KH2PO4. Increased P(i) sorption from dairy slurry was correlated with Fe and Al desorption. Reduction of P(i) sorption capacity from swine slurry was related to preferential sorption of organic P. Additional studies need to be conducted to determine how differences in P sorption between manures and fertilizer impact in-field P availability to a crop and potential for losses in runoff water.

Diagnosis of Parkinson's disease on the basis of clinical and genetic classification: a population-based modelling study.

BACKGROUND: Accurate diagnosis and early detection of complex diseases, such as Parkinson's disease, has the potential to be of great benefit for researchers and clinical practice. We aimed to create a non-invasive, accurate classification model for the diagnosis of Parkinson's disease, which could serve as a basis for future disease prediction studies in longitudinal cohorts. METHODS: We developed a model for disease classification using data from the Parkinson's Progression Marker Initiative (PPMI) study for 367 patients with Parkinson's disease and phenotypically typical imaging data and 165 controls without neurological disease. Olfactory function, genetic risk, family history of Parkinson's disease, age, and gender were algorithmically selected by stepwise logistic regression as significant contributors to our classifying model. We then tested the model with data from 825 patients with Parkinson's disease and 261 controls from five independent cohorts with varying recruitment strategies and designs: the Parkinson's Disease Biomarkers Program (PDBP), the Parkinson's Associated Risk Study (PARS), 23andMe, the Longitudinal and Biomarker Study in PD (LABS-PD), and the Morris K Udall Parkinson's Disease Research Center of Excellence cohort (Penn-Udall). Additionally, we used our model to investigate patients who had imaging scans without evidence of dopaminergic deficit (SWEDD). FINDINGS: In the population from PPMI, our initial model correctly distinguished patients with Parkinson's disease from controls at an area under the curve (AUC) of 0·923 (95% CI 0·900-0·946) with high sensitivity (0·834, 95% CI 0·711-0·883) and specificity (0·903, 95% CI 0·824-0·946) at its optimum AUC threshold (0·655). All Hosmer-Lemeshow simulations suggested that when parsed into random subgroups, the subgroup data matched that of the overall cohort. External validation showed good classification of Parkinson's disease, with AUCs of 0·894 (95% CI 0·867-0·921) in the PDBP cohort, 0·998 (0·992-1·000) in PARS, 0·955 (no 95% CI available) in 23andMe, 0·929 (0·896-0·962) in LABS-PD, and 0·939 (0·891-0·986) in the Penn-Udall cohort. Four of 17 SWEDD participants who our model classified as having Parkinson's disease converted to Parkinson's disease within 1 year, whereas only one of 38 SWEDD participants who were not classified as having Parkinson's disease underwent conversion (test of proportions, p=0·003). INTERPRETATION: Our model provides a potential new approach to distinguish participants with Parkinson's disease from controls. If the model can also identify individuals with prodromal or preclinical Parkinson's disease in prospective cohorts, it could facilitate identification of biomarkers and interventions. FUNDING: National Institute on Aging, National Institute of Neurological Disorders and Stroke, and the Michael J Fox Foundation.