To determine potential, long-term deficits associated with early childhood diarrhea and parasitic infections, we studied the physical fitness (by the Harvard Step Test) and cognitive function (by standardized tests noted below) of 26 children who had complete surveillance for diarrhea in their first 2 years of life and who had continued surveillance until 6–9 years of age in a poor urban community (favela) in Fortaleza in northeast Brazil. Early childhood diarrhea at 0–2 years of age correlated with reduced fitness by the Harvard Step Test at 6–9 years of age (P 0.03) even after controlling for anthropometric and muscle area effects, anemia, intestinal helminths, Giardia infections, respiratory illnesses, and socioeconomic variables. Early childhood cryptosporidial infections (6 with diarrhea and 3 without diarrhea) were also associated with reduced fitness at 6–9 year of age, even when controlling for current nutritional status. Early diarrhea did not correlate with activity scores (P 0.697), and early diarrhea remained significantly correlated with fitness scores (P 0.035) after controlling for activity scores. Early diarrhea burdens also correlated in pilot studies with impaired cognitive function using a McCarthy Draw-A-Design (P 0.01; P 0.017 when controlling for early helminth infections), Wechsler Intelligence Scale for Children coding tasks (P 0.031), and backward digit span tests (P 0.045). These findings document for the first time a potentially substantial impact of early childhood diarrhea and cryptosporidial infections on subsequent functional status. If confirmed, these findings have major implications for calculations of global disability adjusted life years and for the importance and potential cost effectiveness of targeted interventions for early childhood diarrhea.

Diarrhea persists as a major health threat for children in developing areas. It remains a leading cause of mortality worldwide, causing more than 3 million deaths each year. 1 However, the true long-term impact among those who live through repeated or prolonged diarrheal illnesses is poorly defined and likely under-recognized. 2 Children in impoverished urban areas of northeast Brazil have rates of diarrheal illnesses that are among the highest in the world in their first 2 years of life, 3 with enterotoxigenic and enteropathogenic Escherichia coli, rotaviruses, and Norwalk-like viruses predominating in acute diarrhea3, 4 (Lima AAM and others, unpublished data), and Cryptosporidium, enteroaggregative E. coli, and toroviruses predominating in persistent diarrhea. 5–8 The global economic disparity is also typified in the state of Ceará where nearly half of the families earn less than $113 per month, many families having at least five members. 9 Favelas are extremely poor urban communities where sewage is visible, mud-brick houses often have only 1–2 rooms, and most have no running water and have pit or no toilets. In this setting, we explored the relationships of early childhood diarrhea with subsequent physical fitness, physical activity, and, in pilot studies, cognitive function. Few, if any, studies have been conducted to examine the relationship of early childhood diarrheal illnesses to longterm physical fitness and activity or cognitive function. Adams and others conducted a randomized controlled trial of albendazole treatment of children in Kenya with T. trichiura