Abstract
To reduce the burden of early-life linear growth faltering in low- and middle-income countries, interventions have focused on nutrition strategies, sometimes combined with water quality, sanitation, and hygiene (WASH). However, even when combined, their effects on linear growth have been inconsistent. Here, we investigate potential predictors of length-for-age z-scores (LAZ) in a cohort of resource-poor rural Indonesian infants to inform the optimal strategies to reduce linear growth faltering. Apparently healthy rural breastfed Indonesian infants were randomly selected from birth registries at age 6 months (n = 230) and followed up at 9 (n = 202) and 12 (n = 190) months. Using maximum likelihood estimation, we examined longitudinal relationships among socio-demographic status, maternal height, infant sex, age, water source, sanitation facility, energy, protein, micronutrient intakes and biomarkers (serum ferritin, zinc, retinol binding protein (RBP), selenium–adjusted for inflammation), and α-1-acid glycoprotein (AGP) and C-reactive protein (CRP) (systemic inflammation biomarkers) at age 6 and 9 months on LAZ at age 9 and 12 months. Stunting (LAZ <-2) at 6, 9, and 12 months was 15.7%, 19.3%, and 22.6%, respectively. In the full model, the predictor variable at age 6 months that was most strongly associated with infant LAZ at 9 months was maternal height (0.18 (95% CI 0.03, 0.32) SD). At age 9 months, the strongest predictors of LAZ at 12 months were improved drinking water source (-0.40 (95% CI -0.65, -0.14) vs. not improved), elevated AGP compared to not elevated (0.26 (95%CI -0.06, 0.58), maternal height (0.16 (95% CI 0.02, 0.31) SD), sex (0.22 (95% CI -0.02,0.45) female vs. male), serum RBP (0.12 (95% CI -0.01, 0.25) SD), and protein intake (0.17 (95% CI -0.01, 0.35) SD). Health promotion that includes exclusive breastfeeding up to the first six months and follows microbial water quality guidelines to ensure water intake is always safe should be considered.
Highlights
Multiple factors influence linear growth during early childhood, many of which contribute to the burden of stunting, especially in low resource settings
In our household follow-up investigation, fecal contamination at the point of collection was found in almost all households categorized as having an “improved” water source, which persisted in nearly 50% of the households after boiling or giving other treatments to the drinking water at the point of use
The unexpected negative influence of “improved” water source on length-for-age zscores (LAZ) was the strongest association likely linked in part to fecal contamination of the drinking water which persisted even after boiling in some households
Summary
Multiple factors influence linear growth during early childhood, many of which contribute to the burden of stunting, especially in low resource settings. The World Health Organization (WHO) has set a global target to reduce stunting worldwide by 40% in 2025 to reduce the impairments associated with linear growth retardation [1]. These impairments may include delays in cognitive and motor development which can persist into adulthood [2]. In low and middle-income countries, interventions focusing on the influence of the individual or combined effects of water quality, sanitation, and hygiene (WASH) on child growth [4], sometimes in conjunction with nutrition-specific strategies [5,6], have been investigated. Even when combined, their effects on linear growth during infancy and early childhood have been inconsistent [5,6]
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