Tag Archives: child undernutrition

Launch of Cochrane Review on WASH and Chilhood Undernutrition

Launch of Cochrane Review on WASH and Chilhood Undernutrition – Nov 6, 2013. | Source: SHARE

The UK Launch of the Cochrane Review on WASH and Childhood Undernutrition was held yesterday at the London School of Hygiene and Tropical Medicine (LSHTM). Lead author Dr Alan Dangour, Senior Nutrition Lecturer at LSHTM, presented the findings, followed by comments from a distinguished panel including Ms Anna Taylor, Senior Nutrition Advisor at the UK Department for International Development (DFID), Mr Girish Menon, Director or International Programmes and Deputy Chief Executive at WaterAid and Professor Sandy Cairncross OBE of LSHTM.

This study was funded by DFID through the SHARE Research Consortium and provides a definitive synthesis of the current evidence relating improvements in drinking water, sanitation and hygiene (WASH) to childhood undernutrition. The study has attracted much interest in the scientific community as well as in the media, including stories in the BBC and in the Independent. UK-Launch-Cochrane-Review-201317

The full Cochrane Review can be accessed here. In brief, the evidence suggests that WASH interventions confer a benefit on growth in children under five years of age. These findings make an invaluable contribution to the area of child health. Almost 220 million children under the age of five years in low income countries suffer from chronic or acute undernutrition, which increases the risks of illness and death in childhood. Research and experience have shown that food-based interventions to tackle this problem cannot alone provide the solution, pointing to the importance of environmental factors. By consolidating and synthesising available research on the links between WASH and under nutrition this review provides an initial evidence base in favour of putting greater emphasis on WASH in nutrition interventions and lays the groundwork additional research in this area.

Anna Taylor spoke on the strength of this evidence base in relation to similar evidence on comparative nutrition interventions. She also highlighted the challenge that lies ahead, of applying these findings to create meaningful integration of programmes aimed at improving nutritional outcomes in children under the age of five. One important step forward, she said, would be to use this new evidence to make a compelling case for including WASH as a nutrition specific intervention to add to the existing ten interventions recommended in the Lancet Series on Maternal and Child Nutrition published in June this year.

Sandy Cairncross remarked on how this work on the linkages between WASH contributes to a long tradition of such thinking. Some of the earliest studies of the health impact of water and sanitation were by nutritionists: Leonardo Mata in Central America and Andrew Tomkins in Nigeria.

Girish Menon’s comments helped set the context for discussion on how to bring the research findings to life at a programmatic level, with examples of how WaterAid is taking this agenda forward through piloting of integrated WASH/nutrition interventions.

Making hygiene the central issue

I’ve just had the luxury of sitting down and reading a pile of reports that have been accumulating over the last few months.   A group of these relates to the clear links between sanitation and under-nutrition, especially, how the prevalence of open defecation (OD) in India is clearly correlated with stunting in children in that country. The relevant documents, being a report by Dean Spears (How much international variation in child height can sanitation explain) and an article by Robert Chambers and Gregor von Medeazza (Sanitation and stunting in India: undernutrition’s blind spot) are a must-read for all WASH practitioners and child health specialists, and provide ammunition by the bucket load for advocates of better sanitation and hygiene.

One comment in the Chambers/von Medeazza paper, however, stirred up a problem that has been gnawing away at me for a while: “OD is particularly harmful where population density is high”. There is nothing surprising there, we would all agree. So, here is the troubling thought: you might think that the converse applies: perhaps OD is not especially harmful where population density is not particularly high? The situation where someone defecates in a remote field, in a very dry location, and buries the faeces under a desiccating sun is one that has probably occurred to all of us as being not hugely problematic, especially if that person has and uses an effective method of washing his/her hands quickly afterwards.

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Child undernutrition, tropical enteropathy, toilets, and handwashing

The impact of sanitation and hygiene on child mortality and health has been underestimated, contends Dr Jean Humphrey in The Lancet of 19 September 2009 [free registration required].

“Of the 555 million preschool children in developing countries, 32% are stunted and 20% are underweight. Child underweight or stunting causes about 20% of all mortality of children younger than 5 years of age and leads to long-term cognitive deficits, poorer performance in school and fewer years of completed schooling, and lower adult economic productivity.”

“A key cause of child undernutrition is a subclinical disorder of the small intestine known as tropical enteropathy”, Dr. Humphrey states, which “is caused by faecal bacteria ingested in large quantities by young children living in conditions of poor sanitation and hygiene”. “Provision of toilets and promotion of handwashing after faecal contact could reduce or prevent tropical enteropathy and its adverse effects on growth”. “The primary causal pathway from poor sanitation and hygiene to undernutrition is tropical enteropathy and not diarrhoea”.

Dr. Humphrey concludes that “that prevention of tropical enteropathy, which afflicts almost all children in the developing world, will be crucial to normalise child growth, and that this will not be possible without provision of toilets”.

Full reference:

Humphrey, J.H. (2009). Child undernutrition, tropical enteropathy, toilets, and handwashing. The Lancet ; vol. 374, no. 9694 ; p. 1032-1035. doi:10.1016/S0140-6736(09)60950-8

In an earlier WHO study, the authors estimated that 860 000 deaths per year in children under five years of age were “caused directly and indirectly by malnutrition induced by unsafe water, inadequate sanitation and insufficient hygiene”. This raises the total number of children that die every year as a result of unsafe water, inadequate sanitation or insufficient hygiene to 2.2 million instead of the 1.4 million usually quoted.

Full reference:

Pruss-Ustun, A.; Bos, R.; Gore, F. and Bartram, J. (2008). Safer water, better health : costs, benefits and sustainability of interventions to protect and promote health. Geneva, Switzerland, World Health Organization (WHO). Read the full report [PDF file].