Healthy development of the gut microbiome provides long-term health benefits. Children raised in countries with high infectious disease burdens are frequently exposed to antibiotics and diarrheal pathogens, which perturb gut microbiome assembly. A recent cluster-randomized trial
MainNormal assembly of the early-life gut microbiome is critical for human health. The gut microbiome is seeded during birth and stabilizes to an adult-like configuration by the third year of life. 1 The progressive, unperturbed colonization of the intestinal tract during this time window is likely essential to the establishment and maturation of multiple developmental pathways related to metabolism, allergy development, weight gain, disease susceptibility, and mental health. [2][3][4][5] Children raised in low-and middle-income countries (LMICs) are at high risk of early-life environmental insults that might disrupt optimal gut microbiome development. Due to poor sanitation and lack of access to clean drinking water, children living in poverty are frequently exposed to enteric pathogens. 6 Pathogen establishment and proliferation in the intestinal tract can perturb the normal gut microbiome by triggering local and systemic inflammation. 7,8 In areas with a high infectious disease burden, children also frequently consume antibiotics. In urban Bangladesh, children younger than two years are treated with antibiotics at a rate more than five-times higher than that among similarly aged children in the United States. 9,10 Frequent antibiotic use early in life diminishes gut microbiota diversity, enriches for antibiotic resistance genes (ARGs), and reduces microbiome richness while increasing variability. 11,12 In the United States, these perturbations have been linked to increased risk of multiple childhood-onset health disorders, including asthma, allergy rhinitis, and attention deficit hyperactivity disorder. 5 Water chlorination is a promising strategy for reducing exposure to enteric pathogens and associated antibiotic use among young children in LMICs, 13 with potential benefits for the gut microbiome and long-term health. Chlorination inactivates many microorganisms present in water and reduces recontamination during transport and storage. 14 By reducing children's exposures to pathogens, chlorination could prevent the early establishment and proliferation of pathogens in the gut and the subsequent use of antibiotics. However, water chlorination could indirectly affect the developing gut microbiome in other ways. Chlorination does not inactivate all