ESPEYB16 13. Global Health for the Paediatric Endocrinologist Growth and Nutrition (4 abstracts)
13.13. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial
Humphrey JH , Mbuya MNN , Ntozini R , Moulton LH , Stoltzfus RJ , Tavengwa NV , Mutasa K , Majo F , Mutasa B , Mangwadu G , Chasokela CM , Chigumira A , Chasekwa B , Smith LE , Tielsch JM , Jones AD , Manges AR , Maluccio JA & Prendergast AJ
for the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial Team, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA; Global Alliance for Improved Nutrition, Washington, DC, USA; Ministry of Health and Child Care, Harare, Zimbabwe; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA; Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA; Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA; University of British Columbia, Vancouver, BC, Canada; Middlebury College, Middlebury, VT, USA; and Blizard Institute, Queen Mary University of London, London, UK, jhumphrey@zvitambo.co.zw
Lancet Glob Health 2019;7: e132–47. DOI: 10.1093/cid/civ844
• This cluster-randomised, community-based trial investigates whether the combination of a water, sanitation and hygiene (WASH) intervention and of improved infant and young child feeding (IYCF) intervention improves stunting and anemia in children living in rural Zimbabwe.
• Stunting decreased with IYCF, but WASH had no additional effect. Prevalence of diarrhea was not affected by the intervention.
The WASH intervention aims at improving conditions of water, sanitation, and hygiene. The rationale is that WASH will decrease fecal ingestion and as a consequence improve chronic inflammation and environmental enteric dysfunction (EED), regarded as a major underlying cause of both stunting and anemia. The IYCF intervention provides 20 g/d of Nutributter from 6 to 18 months and promotes optimal use of locally available foods for complementary feeding (1). The IYCF intervention alone increased haemoglobin concentrations, reduced stunting by 21%, reduced anaemia by 24%, and increased weight for height, confirming previous studies. WASH, in contrast with a study in Bangladesh but consistent with other trials, was ineffective either by itself or in combination with IYCF.
The authors discuss the possible reasons for the failure of the WASH intervention. First, although there was a good uptake of WASH at a household level, this was much more modest at the community level. Second, previous research has shown that the intensity of WASH implementation is an important factor, and its intensity may not have been high enough in this trial. We also wonder whether the beneficial effects of breastfeeding (immunoprotection) could have masked the effects of WASH. These children were breastfed exclusively until age 6 months and >97% were still at least partially breastfed at 18 months. Finally, the authors only report height SD, not height velocities which could show different results, in particular after exclusive breastfeeding stopped. These data are available and will likely be reported in a subsequent paper. Thus, the lack of effect of WASH observed here does not necessarily mean that it is generally ineffective but maybe its implementation needs to be optimized (2).
References: 1. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial Team. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial: Rationale, Design, and Methods. Clin Infect Dis 2015;61(S7):S685–702.
2. Maleta KM, Manary MJ. WASH alone cannot prevent childhood linear growth faltering. Lancet Glob Health 2019;7: e16.
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ESPE Yearbook of Paediatric Endocrinology
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