Independent and combined effects of improved water, sanitation, and hygiene (WASH) and improved complementary feeding on early neurodevelopment among children born to HIV-negative mothers in rural Zimbabwe: Substudy of a cluster-randomized trial

Abstract

BackgroundGlobally, nearly 250 million children (43% of all children under 5 years of age) are at risk of compromised neurodevelopment due to poverty, stunting, and lack of stimulation. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH) and improved infant and young child feeding (IYCF) on early child development (ECD) among children enrolled in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe.Methods and findingsSHINE was a cluster-randomized community-based 2×2 factorial trial. A total of 5,280 pregnant women were enrolled from 211 clusters (defined as the catchment area of 1–4 village health workers [VHWs] employed by the Zimbabwean Ministry of Health and Child Care). Clusters were randomly allocated to standard of care, IYCF (20 g of small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counseling), WASH (ventilated improved pit latrine, handwashing stations, chlorine, liquid soap, and play yard), and WASH + IYCF. Primary outcomes were child length-for-age Z-score and hemoglobin concentration at 18 months of age. Children who completed the 18-month visit and turned 2 years (102–112 weeks) between March 1, 2016, and April 30, 2017, were eligible for the ECD substudy. We prespecified that primary inferences would be drawn from findings of children born to HIV-negative mothers; these results are presented in this paper. A total of 1,655 HIV-unexposed children (64% of those eligible) were recruited into the ECD substudy from 206 clusters and evaluated for ECD at 2 years of age using the Malawi Developmental Assessment Tool (MDAT) to assess gross motor, fine motor, language, and social skills; the MacArthur–Bates Communicative Development Inventories (CDI) to assess vocabulary and grammar; the A-not-B test to assess object permanence; and a self-control task. Outcomes were analyzed in the intention-to-treat population. For all ECD outcomes, there was not a statistical interaction between the IYCF and WASH interventions, so we estimated the effects of the interventions by comparing the 2 IYCF groups with the 2 non-IYCF groups and the 2 WASH groups with the 2 non-WASH groups. The mean (95% CI) total MDAT score was modestly higher in the IYCF groups compared to the non-IYCF groups in unadjusted analysis: 1.35 (0.24, 2.46; p = 0.017); this difference did not persist in adjusted analysis: 0.79 (−0.22, 1.68; p = 0.057). There was no evidence of impact of the IYCF intervention on the CDI, A-not-B, or self-control tests. Among children in the WASH groups compared to those in the non-WASH groups, mean scores were not different for the MDAT, A-not-B, or self-control tests; mean CDI score was not different in unadjusted analysis (0.99 [95% CI −1.18, 3.17]) but was higher in children in the WASH groups in adjusted analysis (1.81 [0.01, 3.61]). The main limitation of the study was the specific time window for substudy recruitment, meaning not all children from the main trial were enrolled.Conclusions...

Early child development in children who are HIV‐exposed uninfected compared to children who are HIV‐unexposed: observational sub‐study of a cluster‐randomized trial in rural Zimbabwe

“…Among 5280 enrolled pregnant women, there were 738 HIV‐exposed and 3989 HIV‐unexposed live births; of these, 323 HIV‐exposed and 1655 CHU were assessed in the ECD sub‐study at two years of age (Figure ). Mothers of children included in the ECD sub‐study were about two years older compared to mothers of those not included; other baseline characteristics were broadly similar (as reported previously and shown in Table ).…”

“…Overall, 5280 pregnant women were recruited from 211 clusters at a median gestational age of 12.5 weeks and randomized to standard‐of‐care (SOC); IYCF (20 g small‐quantity lipid‐based nutrient supplement (SQ‐LNS) per day from six to eighteen months of age, complementary feeding counselling); WASH (ventilated improved pit latrine and 2 hand‐washing stations, monthly liquid soap and chlorine, a play‐space to separate children from livestock and to reduce geophagia, hygiene counselling); or IYCF plus WASH (all interventions). The primary findings and ECD findings among a subgroup of children at 24 months have been reported previously, stratified by maternal HIV status .…”

“…We used several different developmental assessment tools across a broad range of domains, and specifically adapted them for use in rural Zimbabwe (for example, all toys were bought locally and therefore likely to be familiar to children). The MacArthur Bates CDI is a detailed assessment of language, including both vocabulary and grammar, and we adapted and validated the assessment for use among Shona‐speaking households. We also undertook rigorous quality control throughout the study period, to optimize reliability.…”

“…The purpose of this analysis was to estimate the differences in ECD outcomes at 24 months of age between CHEU and CHU. We have previously reported the effects of the randomized SHINE interventions, which differed between these two groups of children . Among CHU, there was little evidence of effect of either intervention on any measure of child development; by contrast, among CHEU, there were large benefits of the combined IYCF plus WASH intervention on MDAT and MacArthur CDI vocabulary scores, but no evidence of effects from either the IYCF or WASH intervention when implemented alone.…”

Do effects of early life interventions on linear growth correspond to effects on neurobehavioural development? A systematic review and meta-analysis

“…We calculated pooled effect sizes if at least five studies reported an intervention versus control group comparison in any category of intervention (eg, nutritional supplementation and promotion of responsive care and learning opportunities). We applied the same criterion to stratified 29 Ong et al 37 Jeon et al 41 Lind et al 31 Rosado et al 15 Oelofse et al 52 Nahar et al 48 Smuts et al 62 Husaini et al 50 Phuka et al 21 Maleta et al 17 Krebs et al 54 Bauserman et al 55 Faber et al 14 Hess et al 16 Dewey et al 20 77 Luby et al 23 Stewart et al 22 Gladstone et al 61 Lees et al 80 Hallamaa et al 82 Tomlinson et al 78 Tumwine et al 79 Dewey et al 20 Adu-Afarwuah et al 18 Ashorn et al 19 Zhang et al 59 Thomas et al 60 Gowachirapant et al 51 Hamadani et al 35 Jacobson et al 58 Schmidt et al 53 Hanieh 36 Zhu et al 56 Nguyen et al 34 Christian et al 40 Gonzalez-Casano 87 Tofail et al 49 In utero 3 6 9 12 15 18 Months Years 64 Nahar et al 48 Hamadani et al 70 Tofail et al…”