Abstract
SummaryBackgroundChild stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe.MethodsWe did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940.FindingsBetween Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08–0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28–2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported.InterpretationHousehold-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone.FundingBill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.
Highlights
That review was followed by an updated systematic review published just after our trial was completed; it showed that complementary feeding had an effect of 0·11 on length-for-age Z scores in food-secure populations, which is about 5–10% of the deficit experienced by Asian and African children
In seminal research done in The Gambia, child linear growth failure was strongly associated with indicators of environmental enteric dysfunction—increased gut permeability and systemic inflammation resulting from translocation of gut microbes
A meta-analysis of data from Demographic and Health Surveys for low-income and middle-income countries showed an association between linear growth and sanitation, but no randomised trials had been published in which the effect of sanitation on any child health outcome, including diarrhoea, had been tested
Summary
Linear growth faltering (ie, stunting) is the most prevalent form of undernutrition.[1,2] Stunting largely occurs between conception and age 24 months, when mean length-for-age Z scores among Asian and African children plummet to –2·0, with little change thereafter.[1,2] Stunting reduces child survival, educational attainment, and adult economic productivity.[1,2] the offspring of adults who were stunted as children are at increased risk of stunting, creating an intergenerationalLancet Glob Health 2019; 7: e132–47See Comment page e16BC, Canada (A R Manges PhD); Middlebury College, Middlebury, VT, USA (Prof J A Maluccio PhD); and Blizard Institute, Queen Mary University of London, London, UK (Prof A J Prendergast)Research in contextEvidence before this study Before this trial, a Review done for The Lancet Nutrition Series highlighted that child stunting is a highly prevalent condition with adverse short-term and long-term sequelae. The cause of environmental enteric dysfunction has been widely attributed to faecal–oral exposure resulting from living in conditions of poor water, sanitation, and hygiene (WASH) Before this trial, a meta-analysis of data from Demographic and Health Surveys for low-income and middle-income countries showed an association between linear growth and sanitation, but no randomised trials had been published in which the effect of sanitation on any child health outcome, including diarrhoea, had been tested. Many trials of handwashing with soap and chlorination of drinking water showed reductions in diarrhoea, but none reported the effects of these interventions on gut health or child growth Since we began this trial, four published trials have assessed the effect of community-based sanitation on stunting.
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