TITLE: Participant Registration Form For Mapping the Early Childhood Gut Across Ancestry, Geography, and Environment (Gut-AGE) 
AUTHORS: Fatima Zulqarnain, Stephanie Regis, elsy.ngwa, Asra Usmani, jason.boisvert, Arg7Ef, Sana Syed, Jocelyn Silvester, jay.thiagarajah

[DESCRIPTION]
The gastrointestinal (GI) system has a critical role in growth and development during infancy and early childhood, with early development continuing to influence health outcomes into adulthood. Several GI diseases are currently being characterized at single-cell resolution; however, the interpretation of this data is limited by the lack of well-annotated reference data, particularly from healthy infants and young children. The aim of this project is to map the healthy gut in infants and children (age 0-5 years) during a critical developmental window that impacts long-term health outcomes and is shaped by genetics and the environment. We will map early gut development across populations with diverse ancestry and geography, at single-cell resolution, and with linked contextual data on tissue morphology, genetic background, social determinants of health, and environmental exposures. The participant registration form for this study aims to capture clinical metadata – including demographic data (age, weight, height/length, gestational age at birth, etc.), clinical data (reason for biopsy), and nutritional information – to construct a well-annotated reference dataset. 


[STEPS]
SECTION: To be filled out by the study team
1. PARTICIPANT REGISTRATION FORM 

The first part of the form collects registration information from each participant. The purpose of this section is to ensure that the study team has all relevant participant information for accessing participant health records at their site of care. This information will allow study members to link their protected health information (PHI) to their study ID and confirm that participants meet inclusion and/or exclusion criteria at the time of enrollment. Information about the physician involved in the study procedures will help track any protocol deviations or adverse events. This section will also be used to document study consent procedures.

At the end of the consent section, there is a free text space for any comments from the registration process, which can be used to document the refusal of consent for certain samples, the need for accommodations such as an interpreter, etc. 

MMM: months (3 letter - Jan, Feb, Mar...)

 

SECTION: To be filled out by the study team
2. PARTICIPANT’S CLINICAL HISTORY

The clinical history section is taken from the participant's health record. This section can be tailored to the organ system that is the focus of the study. The categories in this protocol will be used to construct a well-annotated, gastrointestinal-focused reference dataset. It was built with input from three American Academy of Pediatrics board-certified pediatric gastroenterologists; thus variables to be collected are focused on the gastrointestinal system. 

Report all variables to two decimal places (e.g., ###.##) when possible.

 

SECTION: To be filled out by the patient&#x27;s family
3. The following questionnaire can be given to the family to fill out, or be filled out in conjunction with one of the study staff, or on the telephone at a later date.   

CHILD’S DEMOGRAPHICS

Demographic data on the race and/or ethnicity of patients is captured to ensure that the study population is representative of the whole population so that any conclusions drawn from the research are generalizable to larger groups. In 1993, the National Institutes of Science (NIH), published the Revitalization Act, which states  “since a primary aim of the research is to provide scientific evidence leading to a change in health policy or standard of care, it is imperative to determine whether the intervention or therapy being studied affects women or men or members of minority groups and their subpopulations differently.” 

In 1997, the NIH issued revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. These standards are commonly used for federal data collection purposes, such as the census, as well as clinical research. The revised standards contain five minimum categories for race: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White. There are two categories for ethnicity: "Hispanic or Latino" and "Not Hispanic or Latino." The categories and definitions provide a common language to promote uniformity and comparability of data on race and ethnicity. In the questionnaire below, and in subsequent questionnaires about the race of other members of the patient's family, we have collapsed race and ethnicity into one question with the possibility to check more than one box.  

As the NIH recommends the above five as minimum criteria, after an extensive literature review, we expanded the "Asian" category to include the East, Southeast, and South Asian to allow for more comprehensive collection of racial data from Asia. The Canadian Census categories (Visible Minority and Population Group Reference Guide, Census of Population, 2021 (statcan.gc.ca)) were used for this expansion. 

 

SECTION: To be filled out by the patient&#x27;s family
4. CHILD’S BIRTH HISTORY
This project is also investigating geography and ancestry. Patient geographical data at the time of their birth is used can be used to study ancestry, environmental exposures, and migration.

A child's birth history also gives pertinent information about their development. Premature birth has been implicated in an increased risk of intraventricular hemorrhage, necrotizing enterocolitis (NEC), and retinopathy of prematurity, all of which can lead to increased morbidity in childhood (Ward et al). 

Small for gestational age (SGA) is defined as a birth weight of less than the 10th percentile for gestational age, according to the 2021 American College of Obstetrics and Gynecology Bulletin. Infants who are SGA have traditionally been divided into two groups: (1) constitutionally normal infants who are SGA and (2) infants who are SGA because of growth restriction. Infants who are constitutionally normal will have a birth weight less than the 10th percentile on population-adjusted growth curves due to maternal height, weight, and/or ethnicity, and will have a decreased risk of perinatal morbidity and mortality compared to their growth-restricted counterparts (Carberry et al). The burden of fetal growth-restricted SGA is higher in resource-poor countries. These children are at higher risk of prematurity, neonatal asphyxia, hypothermia, hypoglycemia, hypocalcemia, polycythemia, sepsis, and death (Liu et al).

 

 

 

 

 

SECTION: To be filled out by the patient&#x27;s family
5. CHILD’S PAST MEDICAL HISTORY

A complete medical history includes an in-depth inquiry into the patient's past medical issues, which includes all diseases or illnesses currently being treated, as well as any other issues that may have residual effects on the patient’s health. As this project focuses on the gastrointestinal system, discussions with three board-certified pediatric gastroenterologists have led us to include the history of common, uncommon, and systemic conditions that may have gastrointestinal manifestations (such as allergies) in this section.  

Heavy metals are high atomic weight elements that naturally occur in the environment and have a density at least 5-times greater than that of water. These include arsenic, cadmium, chromium, copper, lead, mercury, and nickel (Tchounwou et al). Heavy metals are used in a variety of industrial processes and can cause acute and/or chronic toxicity due to environmental exposures. These metals may cause gastrointestinal, kidney, and nervous system dysfunction, vascular damage, immune dysregulation, birth defects, and cancer, among other pathologies (Balali-Mood et al). The table below summarizes common heavy metals, their sources of exposure, and the acute and chronic effects of toxicity. 

  

 

 

 

 

SECTION: To be filled out by the patient&#x27;s family
6. CHILD’S MEDICATIONS

Medication history provides information on exposure when trying to identify associations between medications and outcomes. The outcome measured can be related to structural changes in the target tissue or functional changes in the history of the illness.  

 


SECTION: To be filled out by the patient&#x27;s family
7. DIETARY QUESTIONNAIRE - 24 HOUR RECALL
The diet questionnaire is based on a publication by the World Health Organization called Indicators for assessing infant and young child feeding practices (IYCF)  for ages 2 or younger (World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), 2021); it provides 17 IYCF indicators of diet quality. The WHO IYCF indicators and questionnaire were selected because they represent validated and comprehensive measures of diet quality. For example, the indicators were used by the Demographic and Healthy Surveys (DHS) and UNICEF Multiple Indicators Cluster Surveys (MICS). 

The questions are grouped by nutrient class/type providing a straightforward method of evaluating nutrient status (e.g. Vitamin A, iron, etc) and risk for chronic, noncommunicable diseases. Diet diversity is associated with increased linear growth in children and decreased risk of micronutrient deficiency (World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), 2021). The objective of the diet questionnaire is to understand the participant's approximate macro/micronutrient intake within the past 24 hours which could, in turn, affect what we see in the multiplexed-immunofluorescent images, single-cell sequencing, and other data that we are producing from biopsies and blood collected from participants.


 

SECTION: To be filled out by the patient&#x27;s family
8. FOOD SECURITY 
Hunger Vital Sign™ is a 2-question food insecurity screening tool to identify households at risk of food insecurity. he Hunger Vital Sign™ identifies households as being at risk for food insecurity if they answer that either or both of the following two statements is ‘often true’ or ‘sometimes true’ (vs. ‘never true’). This tool was validated in a survey of 30, 098 families, 23% of which were food insecure and an affirmative response to either question 1 or 2 had a sensitivity of 97% and specificity of 83% and was associated with increased risk of reported poor child health. We added a question regarding food acquisition through federal benefits to assess socioeconomic status. 


 

 

SECTION: To be filled out by the patient&#x27;s family
9. SOCIAL AND ENVIRONMENTAL HISTORY

This study will explore ancestry, geography, and environment. The following sections will provide in-depth insight into these areas while ensuring our results are generalizable across populations:  
SECTION: To be filled out by the patient&#x27;s family
10. PERCEIVED STRESS SCALE

The Perceived Stress Scale (PSS) was developed in 1983 by Cohen et al, and is a self-reported questionnaire designed to measure “the degree to which individuals appraise situations in their lives as stressful” (Cohen et al). The questionnaire generally assesses the degree to which the respondents believe their life has been overwhelming but does not focus on specific events or experiences. The 4-item PSS was adopted from the original 14-item scale, and the respondents answer each question on a five-point scale: never, almost never, sometimes, often, and very often. 

Although the four-item PSS (PSS-4) has a moderate loss in internal reliability in comparison to the 14-item scale (r= 0.60 vsr= 0.85), the brevity of this instrument lends itself well to this study as we are already administering quite a lengthy questionnaire.  

 

 

 

SECTION: To be filled out by the patient&#x27;s family
9.1. Maternal Risk Factors During Pregnancy

 Exposure to maternal risk factors during pregnancy may affect the development of the fetus in-utero and after birth. Any developmental differences may affect what we see in the multiplexed-immunofluorescent images, single-cell sequencing, and other data that we are producing from biopsies and blood collected from participants. 

Anemia during pregnancy is mostly due to iron deficiency and is associated with intrauterine growth retardation, prematurity, fetoplacental miss ratio, and higher risk for peripartum blood transfusion (James). Maternal iron deficiency can also lead to abnormal brain development in the fetus, leading to cognitive deficits in childhood (Georgieff et al). 

Gestational diabetes increases the risk of long-term complications — including obesity, impaired glucose metabolism, and cardiovascular disease — in both the mother and the infant. Exposure to smoke or tobacco in other forms during pregnancy is associated with an increased risk of obstetric complications and adverse health outcomes for children exposed in-utero, while alcohol use as been associated with similar complications as well as a specific constellation of birth defects and intellectual and neurodevelopmental disabilities known as fetal alcohol spectrum disorders (Williams et al). 

 



 

 

 

 

SECTION: To be filled out by the patient&#x27;s family
9.2. Breastfeeding History

World Health Organization called Indicators for assessing infant and young child feeding practices (IYCF)  for ages 2 or younger (World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), 2021) includes indicators for breastfeeding. According to the CDC, infants who are breastfed have reduced risks of asthma, obesity, type 1 diabetes, severe lower respiratory disease, sudden infant death syndrome, gastrointestinal infections (diarrhea/vomiting), and necrotizing enterocolitis, and mothers who breastfeed have lower risks of hypertension, type 2 diabetes, and ovarian and breast cancers. However, due to a variety of factors, breastfeeding is not feasible in some situations. Thus, it is important to obtain a comprehensive history of breastfeeding to assess nutrition. 

 

SECTION: To be filled out by the patient&#x27;s family
9.3. Demographic information about mother and/or father 

For ancestry analysis, we would like to collect demographic information from the parents and grandparents of the patient. Categories analogous to those used for the patient are used for racial and/or ethnic information. Additional demographic information were adapted from the National Health and Nutrition Examination Survey (NHANES) a program of studies designed to assess the health and nutritional status of adults and children in the United States.The NHANES interview includes demographic, socioeconomic, dietary, and health-related questions. These questions give us further insight into the environment of study participants. Additional questions were adapted from the 2020 United States Census questionnaire. 

 

SECTION: To be filled out by the patient&#x27;s family
11. HOUSEHOLD COMPOSITION

Similar to Step 9.3, some of the questions in this section were adapted from the National Health and Nutrition Examination Survey (NHANES) a program of studies designed to assess the health and nutritional status of adults and children in the United States. The NHANES interview includes demographic, socioeconomic, dietary, and health-related questions. These questions give us further insight into the environment of study participants. Additional questions were adapted from the 2020 United States Census questionnaire. 

 

Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS). National Health and Nutrition Examination Survey Questionnaire (or Examination Protocol, or Laboratory Protocol). Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention

The 2020 Census questionnaire can be accessed at: https://www2.census.gov/programs-surveys/decennial/2020/technical-documentation/questionnaires-and-instructions/questionnaires/2020-informational-questionnaire.pdf 
SECTION: To be filled out by the patient&#x27;s family
12. FAMILY MEDICAL HISTORY

The family medical history gives us further information about diseases that occur in the patient's family that may put the patient at a higher risk of developing these diseases.