WASH and Child Growth & Development Washington, DC | May 2-3, 2013 Val Curtis London School Of Hygiene and Tropical Medicine & Alan Dangour, Oliver Cumming,

WASH and Child Growth &

DevelopmentWashington, DC | May 2-3, 2013

Val CurtisLondon School Of Hygiene and Tropical Medicine& Alan Dangour, Oliver Cumming, SHARE, DFID

Clean, Fed & Nurtured: Joining forces to promote child growth and development

WASH basics

• Water – quantity and quality

• Sanitation– Faecal waste

disposal• Hygiene – Hand, Food,

Environment

0.85m deaths a year

2-3.5bn episodes

Source: Liu et al, Lancet 2012

Faeces

Fluids

Fields

Flies

Fingers

FoodsNew Host

Faeces

Fluids

Fields

Flies

Fingers

FoodsNew Host

Faeces

Fluids

Fields

Flies

Fingers

FoodsNew Host

Faeces

Fluids

Fields

Flies

Fingers

FoodsNew Host

Faeces

Fluids

Fields

Flies

Fingers

FoodsNew Host

Faeces

Fluids

Fields

Flies

Fingers

FoodsNew Host

Faeces

Fluids

Fields

Flies

Fingers

FoodsNew Host

Source: Global Water Supply and Sanitation Assessment 2010 Report: WHO and UNICEF, 2012

2.6bn have no safe toilet0.8bn have no safe drinking water20%?? HWWS

WASH and nutrition

Faecal-oral exposure

Diarrhoeal Diseases

Environmental Enteropathy

Nematode infection

Poor WASH

Poor nutritional status

Cochrane Public Health Group

• Includes– RCTs– non-randomised controlled studies– interrupted time series studies

• WASH included as one intervention

Review protocol

• All included studies to have controlled design

• Participants: children < 18 years old

• Intervention types– Improving access to facilities which ensure the hygienic

separation of human excreta from human contact– Promotion of hand washing with soap– Introducing a new/improved water supply and/or improved

distribution– Improving the microbiological quality of drinking water

Outcomes, search strategy• Primary outcomes (z-scores)– Weight-for-height (wasting)– Weight-for-age (underweight)– Height-for-age (stunting)

• Secondary outcomes– All other child anthropometric measures– Biochemical measures of micronutrient status

• 6 databases searched; keyword and MeSH terms• 3 main Chinese databases searched

Search results

Included studies• 12 studies from 10 countries

– Bangladesh (1989; 1993)– Guatemala (1968; 2009)– Pakistan (2012)– Kenya (2011)– Ethiopia (2012)– Nigeria (1990)– Nepal (2011)– Chile (1983)– South Africa (2010)– Cambodia (2011)

• Duration: 6 mo to 5 years• Sample: n=8,500; all <5 years

Interventions• Studies included from 1 to 4 WASH interventions• Interventions– Provision of flocculent water disinfectant– Provision of a protected water supply– Installation of boreholes and hand pumps– Solar water disinfection (SODIS)– Sanitation education– Construction of sanitary facilities– Provision of soap– Promotion of hand washing with soap

Study designs• Multiple designs

– Randomised controlled trials (3)– Follow-up of cluster randomised controlled trial (1)– Longitudinal study with control group (3)– Repeat cross-sectional with control group (3)– Controlled before-and-after study (1)– Cross-sectional with intervention and historic control group

matched by propensity score matching (1)

• No study considered high quality according to Cochrane criteria

Results table n=8,500Study n Reported effect (HAZ unless stated)

Ahmed 1993 298 Mean WAZ: P< 0.05

Arnold 2009 877 MD: 0.04 (-0.19, 0.27)

Bowen 2012 461 MD: -0.08 (-0.29, 0.13)

Du Preez 2010 329 MD: 0.15 (-0.14, 0.44) (not published)

Du Preez 2011 521 MD: 0.12 (-0.15, 0.39)

Fenn 2012 1899 MD: 0.22 (0.11, 0.33)

Guzman 1968 N.D. Mean height: no stat. test

Hasan 1989 405 No statistically different differences

Huttly 1990 180 – 368 Decline in % children with low W/H: P<0.005

Langford 2011 88 MD: -0.13 (-0.54, 0.28)

McGuigan 2012 753 MD: 0.18 (-0.06, 0.42) (not published)

Schlesinger 1983 199 % low weight: P<0.05 for change in control group

HAZ (all studies)

HAZ meta-analysis n=1,603

I2 = 0%

WAZ meta-analysis n=1,616

I2 = 5%

WHZ meta-analysis n=1,605

I2 = 0%

Interpretation

• Number of children included in studies reasonable

• Quality of studies is limited

• Cochrane meta-analysis suggests that WASH improves HAZ by ~0.15 SD

• Supported by IPD analysis

• “Suggestive evidence of benefit”

Concerns

• Publication bias• Quality of studies• Links in the pathway?

Conclusions of Cochrane review

• First systematic review of WASH and nutrition• 12 studies (of mixed quality) provide data for analysis• Suggestive evidence of benefit of WASH on linear growth• More evidence on the way• And still more needed!

WASH and nutrition


Diarrhoeal Diseases


Nematode infection

Poor WASH

Poor nutritional status

Diarrhoea and stunting• Diarrhoea associated with poor nutritional status but

causal link hard to demonstrate

• Poor nutritional status associated with greater risk of diarrhoea (Briend, 1990; Checkley et al, 2002)

• Recent analysis of 9 studies with daily diarrhoea morbidity data and longitudinal anthropometry (Checkley et al, 2008):– Odds of stunting at age 24 mo increased with each diarrhoeal episode before 24 mo

(P<0.001)– Odds of stunting at age 24 mo increased by 1.13 (95% C.I. 1.07, 1.19) for every five

episodes– Consistent with hypothesis that higher cumulative burden of diarrhoea increases risk

of stunting

WASH and nutrition


Diarrhoeal Diseases


Nematode infection

Poor WASH

Poor nutrition

Time, costs, workload

Other Diseases

WASH and ECD


Diarrhoeal Diseases


Nematode infection

Poor WASH

Poor ECD

Time, costs, workload

Other Diseases

Diarrhoea/Giardia and ECDHigh diarrheal disease burdens before 2 years of age linked with

delayed school entry and poorer performance on intelligence tests– Patrick et al 2005.– Lorntz et al 2006

Multiple infections with Giardia associated with a 4-point (0.27 SD) deficit on a standardized intelligence test at 9 years of age.– Berkman et al 2002

Bowen et al 2012...“At 5 to 7 years of age, children randomized to home-based

handwashing promotion during their first 30 months of life attained global developmental quotients more than 6 points (0.4 SD) greater than control children.

The effect size was similar across all 5 domains (adaptive, personalsocial, communication, cognitive, and motor) ...and is comparable to gains after participation in the US publicly funded Head Start preschool program for poor children (SD, 0.33-0.46 compared with parental care) and early intervention programs for premature infants (SD, 0.46)

Such an effect size is regarded as clinically meaningful and some estimate that a societal shift of this magnitude would yield trillions of dollars in increased productivity.”

Conclusions

• Systematic reviews are blunt instruments but the best we have

• All studies need publishing• Ever more evidence to collect? Should that

hold us back? • Is this about competition?

NUTRITION and Child Growth &

DevelopmentWashington, DC | May 2-3, 2013

Kay DeweyUC-Davis and Alive & Thrive


Nutrition Basics• IYCF = infant and young child feeding, to 2 years• WHO-recommended feeding practices for:

– Breastfeeding (early initiation; exclusive BF; continued BF)– Complementary feeding (e.g. amount, consistency, frequency,

diversity & types of foods), including:• Safe preparation & storage of complementary foods (relevant to WASH)• Responsive feeding practices (relevant to ECD)

• Established indicators:– Feeding practices (8 core WHO/UNICEF indicators)– Anthropometric measures (e.g., weight for age, height for age,

weight for height, arm circumference)• Reduction in stunting (very short height for age) is a key goal

Key window for nutrition interventions

Preconception through pregnancy

0-6 mo: Exclusive breastfeeding

6-24 mo: Complementary feeding

Guiding principles for complementary feeding (2003; 2005)

Outline

• Impact of nutrition interventions on linear growth (child’s height)

• Impact of nutrition on child development• The need for combined interventions

Impact of nutrition onchild growth

Prenatal nutrition interventions

• Iron & folic acid supplements• Multiple micronutrient

supplements• Balanced protein-energy

supplements• Fortified foods for pregnant

women

• Potential for major impact on stunting, but evidence is mixed


A. Multiple micronutrient supplements (usually compared with iron & folic acid)

Meta-analysis in 2009 (Fall et al.): • Small but significant increase in birth weight (+22 g) but not birth

length (+0.06 cm)– Measurement issues?

• 11-17% reduction in low birth weight• Impact only evident in mothers with higher BMI

Meta-analysis in 2012 (Ramakrishnan et al.):• Increase in mean birth weight (+53 g); data on birth length not

presented• 14% reduction in low birth weight


B. Balanced protein-energy supplementation

Meta-analysis in 2003 (Kramer & Kakuma):• Increase in mean birth weight (+38 g) but not birth length (+0.1 cm)• 32% reduction in small-for-gestational-age births• Larger effect on birth weight in hungry season and in

undernourished women

Meta-analysis in 2012 (Imdad & Bhutta):• Increase in mean birth weight (+73 g); did not report birth length• 32% reduction in LBW and 34% reduction in SGA births• Larger effect on birth weight in undernourished women


C. Fortified foods for pregnant women

Lipid-based nutrient supplement (LNS) (Huybregts et al. Am J Clin Nutr 2009), Burkina Faso

• LNS: 373 kcal/d & similar micronutrients as MMN tablets• LNS group (compared to MMN):

– Birth weight +31 g (p=0.2)– Birth length +0.46 cm (p=0.001)

• effect greater in mothers with BMI < 18.5 (+1.2 cm)

• Same research group previously showed that MMN (vs. control) increased birth length by 0.36 cm; thus predicted impact of LNS vs. control would be 0.46 + 0.36 = 0.82 cm (effect size 0.33)

Exclusive breastfeeding 0-6 mo• Large impact on infant survival • Little evidence of impact on stunting

– Effect may be more likely in populations with high rates of infection during the first 6 mo postpartum, where promotion of exclusive breastfeeding may reduce infection and thus be more likely to promote linear growth than in populations where such infections are less common

– Insufficient evidence to evaluate this question at present

46

Complementary feeding 6-24 mo

• Several strategies:– Educational approaches– Increasing energy density

of complementary foods– Provision of

complementary food– Fortification

• Potential for major impact on stunting but evidence is mixed

47

6-24 mo: Complementary feeding Guiding principles for

complementary feeding (2003; 2005)

Complementary Feeding - 1

• Educational approaches – mixed results– Most showed little or no impact– Peru study illustrated substantial potential to

improve linear growth (Effect size=0.5): emphasized consumption of nutrient-rich animal-source foods & was conducted in a population where animal-source foods were available & affordable

– Two recent studies (Shi et al.; Vazir et al.) show modest impact (Effect size ~0.2): both emphasized key messages including dietary diversity and animal-source foods


• Interventions to increase energy density – mixed results– Of 5 studies, 2 had positive impact but 3 had no

impact on energy intake or growth– May be effective when traditional complementary

food has low energy density & infant unable to compensate by increasing volume of food consumed or feeding frequency


• Provision of complementary food – mixed results– Average effect size ~0.2-0.3, but wide range• May depend on food security of target population• May depend on nutrient quality of food provided

– Two studies directly compared food + education vs. education only (both in S Asia): somewhat greater impact when food included


• Fortification (or improved bioavailability) alone has little effect on linear growth– Exception: fortified vs. unfortified milk powder in India

• Combination of macro- and micro-nutrients in may have a larger impact

• Nutrient quality of fortified products is likely to be important– Amount and bioavailability of nutrients needed for

growth– Inclusion of milk– Essential fatty acids

Summary of impact of nutrition interventions on stunting

• Nutrition interventions (alone) have had a modest impact on linear growth– Need to be realistic about expected impact of

nutrition interventions • However, impact on % with very low height

(stunting) may be larger than effect on mean height

Impact of nutrition onchild development

Potential mechanisms for the effect of nutrient deficiency on children’s

cognitive, motor, and socio-emotional development

From: Prado & Dewey, A&T Technical Brief

Nutrition and Brain Development in Early Life (Prado & Dewey, A&T Technical Brief)

1) Adequate nutrition during pregnancy and the first two years is necessary for normal brain development, laying the foundation for future cognitive and social ability, school success, and productivity.

2) Priority should be given to the prevention of: • Severe acute malnutrition• Intrauterine growth retardation • Stunting• Iron-deficiency anemia• Iodine deficiency

Nutrition and Brain Development in Early Life (Prado & Dewey, A&T Technical Brief)

3) There is growing evidence for beneficial effects on ECD of:• Breastfeeding promotion • Pre- and post-natal multiple micronutrient supplementation• Pre- and post-natal supplementation with essential fatty acids• Fortified food supplements provided during pregnancy and to

the child from 6 to 24 mo

4) An integrated approach is likely to be most effective for promoting optimal child development, i.e., interventions that combine improved nutrition with other strategies such as enhancing the home environment and the quality of caregiver-child interaction.

The need forcombined interventions

Nutrition, infection control & care Prenatal + postnatal (and possibly pre-conception) Macronutrients + micronutrients: Adequate supply of

macronutrients may be needed to ensure growth response to micronutrients

How nutrition can reduce the negative impact of infections on child growth

1. Strengthening the immune system, thereby reducing the severity and duration of infections

2. Providing extra amounts of nutrients to compensate for poor absorption during infection, losses during diarrhoea, reallocation due to immune system activation or reduced appetite during infection

3. Providing nutrients for catch-up growth following infection, particularly those needed to build lean body tissue such as protein, potassium, magnesium, phosphorus, zinc and sodium

4. Preventing poor appetite caused by micronutrient deficiencies, thereby facilitating catch-up growth

5. Favoring the growth of beneficial bacteria in the gut that enhance gut function and immune defenses

Trials with combined nutrition + infection control are underway

• WASH Benefits (water, sanitation and hygiene interventions: singly, combined or in combination with nutrition intervention)

• SHINE (independent and combined effects of improved water, sanitation and hygiene and improved infant feeding)

Both target mainly the postnatal period

Little evidence on impact of combined pre- and postnatal nutrition interventions

• Key trials conducted in 1970s• INCAP trial in Guatemala– Fortified food (atole) with high milk content

• Bogota study in Colombia– Child’s food ration included milk

• Intervention trial with fortified food supplements provided both pre- and postnatally not attempted since

Trials with combined pre- and postnatal nutrition are underway

• iLiNS Project: iLiNS-DYAD trials in Malawi and Ghana– Efficacy of maternal LNS given during pregnancy & first 6 mo

postpartum + child LNS given 6-18 mo• The Early Nutrition and Immune Development (ENID)

Trial in the Gambia– Efficacy of prenatal and infancy nutritional supplementation,

focused on infant immune development• Rang-Din Nutrition Study in Bangladesh

– Program efficacy study with 4 arms – one arm includes maternal LNS given during pregnancy & first 6 mo postpartum + child LNS given 6-24 mo

Next steps?

• Evaluate impact of combined prenatal and postnatal nutrition, ECD enrichment and prevention/control of infection throughout the 1000 days– Efficacy– Effectiveness

• Understand role of pre-conception nutrition (trials underway)

• Understand role of maternal mental health

Early Child Development

Washington, DC | May 2-3, 2013Maureen Black, Ph.D.

University of Maryland School of Medicine


Objectives

• Define Early Child Development• Threats to Early Child Development– Toxic Stress– Undernutrition

• Development of Disparities & Lifespan Perspective• Early Child Development Interventions– Early Learning Opportunities & Responsive Caregiving

• Integrated Interventions

Early Child Development Basics

• Early Child Development– Orderly progression of skills, based on maturation &

adaptation to specific culture/settings– Direct and Indirect relationships– Confusion: ECD refers to the intervention and the outcome

Social-Ecological Theory of Child Development

Distal threats and opportunities reach the child through

Proximal interactions between child & family

Bidirectional interactions

Bronfenbrenner & Ceci, 1994

hp

Do we need to have this religious settings ?

Family Support

School and Community

Services

Child Development: Multiple Contributing Factors

Health Nutrition

LearningOpportunities

Sensitive/ResponsiveCaregiving

Social Protection

Protection from Stress/

Harm

Nutrition is necessary for child development, but

not sufficient!

Threats to Early Development

• Poverty and Undernutrition• Toxic stress• Children can handle, even benefit, from mild stress • Toxic stress • Institutionalization, maltreatment, neglect, trauma,

undernutrition• Lack of caregiver responsivity

Shonkoff , Pediatrics, 2012

How Toxic Stress Undermines Child Development

• Non-reversible changes to children’s physiology– Dysregulation of neuroendocrine system

• Hypothalamic Pituitary Adrenal (HPA) Axis• Elevated cortisol production

– Disrupt inflammatory signaling• Increased susceptibility to illness

Johnson et al., Pediatrics, 2013; 131:319-327

Parent Nurturance/Responsivity

Johnson et al., Pediatrics, 2013; 131:319-327

Buffering effects of nurturant parenting

Hippocampal volume by preschool depression severity & maternal support

Luby, PNAS, 2012;109(8):2854-9

Maternal support in early childhood predicts larger hippocampal volumes at school age.

Positive, responsive relationships can alleviate negative effects of stress (brain structure/function).

Fetus Late Infancy/Toddler Pubertal

Developmental Perspective

Thompson & Nelson, 2000

1000 days




Iron: 0.27 mg/day 11 mg/day 7 mg/day 0–6 months 6-12 months 1-3 years

1000 days




Iron: 0.27 mg/day 11 mg/day 7 mg/day 0–6 months 6-12 months 1-3 years

1000 days

Development of disparities & lifespan perspective

Development of disparities &lifespan perspective

2007 & 2011 Lancet Series on Child Development

• Over 200 million children < age 5 y in low & middle income countries do not reach developmental potential – Nutrition: Chronic undernutrition, micronutrient deficiencies– Lack of early learning opportunities– Extended to social & environmental risks

• Efficacy of early interventions – Early childhood policies & programs to reduce inequalities

– Cost of not investing in child dev programs

– Need for policies/procedures to scale up

www.globalchilddevelopment.org

http://www.globalchilddevelopment.org/

Target of Interventions

• Prenatal– Prevent Toxic stress/LBW/Prematurity

• Infancy– Breastfeeding, complementary feeding – Responsive Parenting– Opportunities for early learning– Routines to promote regulation– Family support

Kramer et al., 2008; 2007 & 2011 Lancet series on Child Development

Early Child Development Intervention

• Early learning opportunities– Play– Explore– Interactions: give & take/serve & return

• Responsive Caregiving– Recognize & interpret child’s cues– Prompt– Developmentally appropriate– Enriching– Basis for responsive feeding

Black & Aboud, 2012

Child opens

mouth & accepts

Caregiver offers another

bite

Child looks away,

mouth shut

Caregiver offers a bite

of food

…………………...Time…………

RESPONSIVE FEEDING BEHAVIORS

PROMOTES HEALTHY EATING & GROWTH PATTERNS

Ummm, maybe she is telling me she wants to feed herself.

Child opens

mouth & accepts


bite

Child looks away,

mouth shut

Child picks up food

& eats

Caregiver waits, smiles,

finger food


of food

…………………...Time…………

PROMOTES HEALTHY EATING & GROWTH PATTERNS

RESPONSIVE FEEDING BEHAVIORS

Child opens

mouth & accepts


bite

Child looks away,

mouth shut


of food

…………………...Time…………

NON-RESPONSIVE FEEDING BEHAVIORS

HINDERS HEALTHY EATING & GROWTH PATTERNS

Oh no, I am late. She has to finish eating.

Child opens

mouth & accepts


bite

Child looks away,

mouth shut

Child Cries & spits

out food

Caregiver holds child &force feeds


of food

…………………...Time…………

HINDERS HEALTHY EATING & GROWTH PATTERNS

NON-RESPONSIVE FEEDING BEHAVIORS

Responsive/Unresponsive Feeding

RESPONSIVE• Provides healthy food on a

regular schedule in a setting conducive to eating

• Caregiver reads infant cues of hunger/satiety

• Responds to infant quickly – Direct & Nurturant– Builds regulatory skills

UNRESPONSIVE• Controlling, indulgent, or uninvolved• Ignores/overrides infant cues• Associated with

⁻ Difficult temperament⁻ Maternal mental health

symptoms⁻ Poor growth (under or

overweight)

Parenting interventions (0-3 yrs)

• Home visits, guidance and support from health providers, and group parent training

• Impacts are larger when:– parents and children participate together – interventions involve modeling and practice of

behavior– most disadvantaged children targeted

Lancet series on child development, 2007, 2011

Preschool interventions (3-5 yrs)

• Preschools improve children's cognitive & social-emotional development: school readiness

• Impact is greatest with high quality programs– Teacher-student ratio– Developmental curriculum– Student exploration– Teacher responsivity


Characteristics of Successful Programs

• Integrated across sectors• Focus on disadvantaged children• Parents as partners with teachers to support children’s

development• Opportunities for children to initiate learning & play• Blend traditional child care, cultural beliefs &

evidence-based practices (curriculum, materials)• Systematic in-service training, supervision, monitoring,

and evaluation


How do Integrated Programs Work?

Child Devel

Intervention Child Development

Direct effect of child development interventionLancet series on child development, 2007, 2011

Social-Emotional

Sensori-Motor

Cognitive/Language


Nutrition


Social-Emotional

Sensori-Motor

Cognitive/Language

Direct effect of nutrition intervention


Nutrition

Child Devel


Social-Emotional

Sensori-Motor

Cognitive/Language

Additive effect of child development & nutrition intervention

Nutritional Supplementation and ECD Intervention in Jamaica

Basel

ine

6 m

os.

12 m

os.

18 m

os.

24 m

os.

80859095

100105110115

Nonstunted Control

Control

ECD Inter-vention

Sup-ple-mentedBoth

Cog

niti

ve t

est

scor

e

Grantham McGregor et al., 1991

DQ/IQ Stunted and Non-stunted Children in Jamaica: Effects of ECD Intervention

Walker et al., 2005

A B C D E

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Non-stunted

Stunted - ECD

Stunted - ctl

SD

Score

A = 9-24 mos, B = 33-48 mos, C = 7-8 yrs, D = 11-12 yes, E = 17-18 yrs.


Nutrition

Child Devel


Social-Emotional

Sensori-Motor

Cognitive/Language

Synergistic effect: Impact of 2 interventions greater than their sum. One intervention enhances the impact of the other intervention.

Tested with an interaction term.

Example of Synergistic Intervention

The effect of zinc supplementation onhand-eye coord. enhanced by participation in a stimulation intervention.

Meeks Gardner et al., AJCN, 2005

Integrated Interventions

Considerations• Sectors differ

(education & nutrition)

• Child development beyond 1000 days

• Overwhelm health care/nutrition system

• Overwhelm caregivers• Outcome??

Rationale• Same sites• First 1000 days• Overlapping goals• Economy of scale• Home/clinic visit – integrated messages• Theory-based conceptualization

Integrated InterventionsQuestions

• Timing & severity of deprivations: Both nutrition and child development

• Timing, intensity, & duration of interventions• 1000 days? Beyond?• Training and Supervision: Ensure integration?• Outcomes and analytic models• Policies and integration across sectors• Sustainability and Scale

Lifespan Benefits of Early Child Development Programs

Ensure adequate nutrition, esp. first 1000 days School readiness (parenting & preschool programs)

Academic success Healthy psychological development

Avoid early pregnancyReduce violence & illegal behavior

Positive earning potential Adult health & civic contribution Strong & healthy children – 2nd gen

Break the Cycle of Poverty and DisparitiesPromote Human Capital

I need opportunities to play and learn with a sensitive, responsive caregiver. Remember, I am your future!

One more thing -

Thank You!

Clean, fed and nurtured?

Diarrhoeal Diseases


Nematode infection

WASH

Child development

Time, costs, workload,

opportunities

Other Diseases

Dinner: Bistro Bistro

1727 Connecticut Ave NW, Washington, DC 20009

Documents

WASH and Child Growth & Development Washington, DC | May 2-3, 2013 Val Curtis London School Of Hygiene and Tropical Medicine & Alan Dangour, Oliver Cumming,