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EE: Going Beyond Nutrition to Understand
Child Growth and Development
Laura Smith Rebecca Stoltzfus,Francis Ngure, Brie Reid, Gretel Pelto, Mduduzi Mbuya,
Andrew Prendergast, Jean Humphrey
Division of Nutritional Sciences
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Stunting and EE: What We Know and….
What we are trying to figure out
Division of Nutritional Sciences
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(Victora et al. 2010)
The “Window of Opportunity” for Improving Nutrition is very small… Pre-pregnancy until 18-24 months of age
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What is causing all this stunting?
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Cause #1: Malnourished Mother
• Malnourished mothers give birth to babies that are smaller and shorter than normal
• 50% of Guatemalan babies are born stunted (Ruel 2001) – Prevalence of stunting at birth not well documented
– Good length data on newborns is very hard to get!
Estimates of 20-50% of stunting is due to intra-uterine factors. Effective macronutrient interventions for pregnant women are not
well established.
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Cause #2: Poor Diet
• Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries – Dewey & Adu-Afarwuah, 2008
– 42 studies/programs, most published 1996-2006
• Children who received interventions gained: – 0.0 – 0.76 Z scores weight-for-age
– 0.0 – 0.64 Z scores length-for-age
The best studies caused a 0.7 Z score improvement. BUT: the average growth deficit of African and Asian children is -2.0 Z
At best, diet solved 1/3 of the problem.
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Cause #3: Diarrhea
• Between 6-18 months of age, children in developing countries have around 9 episodes of diarrhea.
• Many authors reported that diarrhea accounts for 10-80% of growth faltering
• But others contend that children grow at “catch-up rates” between episodes, and thus recover these deficits
The Lancet Nutrition Series (2008) concluded that by implementing sanitation and hygiene interventions with 99% coverage, child malnutrition would be reduced by only 2.4%
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However: Evidence exists that the effect of WASH interventions on linear growth is independent of its effect on diarrhea. In several studies, WASH had a bigger effect on growth than it did on diarrhea
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Peru: (Checkley, et al)
• Children assessed for diarrhea and growth from birth to 2 years
• Household sanitation and water assessed
• What predicted height deficit at 2 years?
16% explained by how much diarrhea the child had experienced
40% explained by the level of sanitation and water in child’s household
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Rural Ethiopia: HH Hygiene Index was the variable most strongly associated with stunting
Alive and Thrive baseline data; F Ngure (2013, in prep)
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Cause #4: The Environmental
Enteropathy Hypothesis
• A subclinical condition of the small intestine, called environmental enteropathy (EE)
• Characterized by: – Flattening of the villi of the gut, reducing its surface area
– Thickening of the surface through which nutrients must be absorbed
– Increased permeability to large molecules and cells (microbes)
• Likely causes: – Too many microbes in the gut
– Effects of toxins on the gut
Decreased nutrient absorption + Infiltration of microbes
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Microbial translocation
Microbial products cross into blood stream
The lining of the gut is only one cell thick
If the gut is injured and becomes permeable, gaps open up between cells
Chronic immune activation
Diverts nutrients from growth to infection-
fighting
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EE is a major cause of post-natal stunting, anemia and immune competence
EE can be prevented or reduced by preventing infants and young children from ingesting human and animal feces through a package of interventions that improve sanitation and hygiene.
Environmental Enteropathy and
Stunting Hypothesis:
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Chronic immune activation
↑ pro-inflammatory cytokines
Immunosenescence (premature aging) of adaptive cell-mediated immune system
↑Hepcidin ↓Growth Factor (IGF-1)
Anemia Stunting Impaired response to vaccines and infections
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HAZ changes over first 18 months in stunted and non-stunted infants
Birth 6wks 3mo 6mo 12mo 15mo 9mo 18mo
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IGF-1 and IGFBP3 were lower in stunted infants, beginning at 6 wk
0 3 6 9 12 15 18
0
20
40
60
80
Age (months)
Me
dia
n IG
F-1
(n
g/m
L)
0 3 6 9 12 15 180
500
1000
1500
IGF
BP
3Months
P values for all time points 6 w to 12 mo, p<0.001 Values for healthy European children range from 54-170 ng/mL
P values for all time points 6 w to 18 mo, p<0.001
stunted stunted
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Development of the WASH Intervention (Efficacy = “Proof of concept”)
WASH Goal:
All infants never ingest any faeces between birth to 18 months
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Conventional WASH formative research (2008-2009)
Sanitation HIGHLY valued don’t have a latrine because lack money; a Blair VIP is a source of status
• Infant stools less offensive than adults’ • Handwashing is seldom with soap • Frequently feed cold leftover food
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• 6 hour observation of 20 babies, recorded what and how often went in the mouth and if visibly dirty • Returned and collected samples of most frequent and dirtiest things mouthed for micro analysis
Baby Observation Study (2011)
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Findings
Most frequent: 38 time in 6 hours 75% visiby dirty
Dirtiest Soil (3 ate avg 11 bites) chicken faeces, stones
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If allowed, toddlers consume poultry feces
Peruvian shantytown families: – Households who owned free-range poultry:
• Average ingestion of poultry feces by toddlers per 12-hour observation period was 3.9 times – Marquis GM et al., Am J Public Health 1990
Rural Zimbabwe: – Not selected for poultry ownership:
• 3 of 7 toddlers directly ate chicken feces during a 6-hour observation period. – Ngure F et al., submitted, 2012
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The context: IO
study
Laundry area
Bare soil and
animal waste
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Micro team
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% HH with E coli + sample
E coil/ Per gram
Average E Coli Per Day
Infant Food 0% 0 0
Drinking Water 54% 2 800
Soil in laundry area
60-80% 70 1,400
Chicken feces 100% 10,000,000 10,000,000
Clearly, kids must stop eating dirt and chicken poop!
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26
Babies are fed on *Ground in the yard (60-80% E coli+) or *Kitchen floor (81% E coli+)
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Laundry Water
Nappy Handling
Protective Play Space
for babies!
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A new way of thinking about WASH in the first 1000 days
• Protective play space, to protect developing child from contaminated soil and animal feces (especially chickens)
• Infant handwashing with soap, when outside of protective play space.
• Caregiver handwashing with soap after fecal contact and before preparing/serving food
• Safe disposal of feces—especially of children
• Water treatment
• Avoid feeding leftovers, or reheat
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Control
Infant Feeding: Education + Nutributter
WASH: Integrated Water,
Hygiene & Sanitation
WASH +
Infant Feeding
2x2 Factorial Design
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Objective
To measure the independent and combined effects of WASH and infant nutrition on stunting and anemia among children from birth to 18 months of age
And, on a sample of 1600 infants, measure the hypothesized “causal pathway” of EE
1000 HIV- mothers
600 HIV+ mothers
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Early Childhood
Development
Nutrition
Stimulation Social
Protection
Hygiene
Programmatic approaches for nutrition, stimulation and social protection are well developed. UNICEF 2006 Programming Experiences in Early
Childhood Development Lancet 2011 Child Development Series
Hygiene for babies (Baby WASH)
needs to be further developed and tested
Environmental Protection?
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Research Priorities
• Identifying the causal pathway by which WASH interventions may interrupt EE and child stunting
• Developing and implementing Baby WASH interventions that support nutrition, hygiene and child development
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SHINE Investigators: MoHCW Goldberg Mangwadu – Director of Environmental Health, MoHCW (Co-PI) Cynthia Chasokela – Director of Nursing
Zvitambo Jean Humphrey (Co-PI) Mduduzi Mbuya, Naume Tavengwa, Kuda Mutasa, Robert Ntozini
Johns Hopkins Bloomberg School of Public Health Larry Moulton, Jim Tielsch (J Humphrey)
Cornell Rebecca Stoltzfus
University of London Andrew Prendergast
University of British Columbia Amee Manges
Funding
Gates, DFID, CIDA, NIH,
Wellcome Trust, UNICEF