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 Sanitation Hygiene Infant Nutrition Efficacy (SHINE)

The SHINE Trial is a community-based trial in rural Zimbabwe recruiting women during the first trimester of pregnancy to investigate the independent and combined effects of improved water, sanitation and hygiene and/or improved infant feeding on child stunting and anemia at 18 months of age.  Birth outcomes such as miscarriage, stillbirth, prematurity, small-for-gestational age and stunted-for-gestational age are being measured, and there is strong evidence that mycotoxin exposures are prevalent and significant in this study population.

The primary goal of SHINE is to identify the underlying causes of and effective solutions to child stunting and anaemia.  Stunting affects nearly one-third of child in low-income countries, causes 20% of all under-5-y mortality, and leads to long-term cognitive deficits, fewer years and poorer performance in school, lower adult economic productivity, and a higher risk that their own children will also be stunted, perpetuating the problem into future generations. Stunting occurs between conception and 2 years of life, after which it is largely irreversible.  Furthermore, the most efficacious dietary interventions only reduce the problem by about one-third.   Anaemia affects 75% of all 6-18 month children in low-income countries and also causes cognitive deficits.  Like stunting, the cognitive deficits incurred during young childhood are largely irreversible, and like stunting, only about half of child anaemia is responsive to the common current public health intervention, iron supplementation.  Thus, stunting and anaemia are foundational child health problems in low-income countries because they are highly prevalent, increase child mortality, result in long-term cognitive deficits, lost human capacity, and lost adult economic productivity, are largely irreversible after 2 years of age, and are onlypartly responsive to current public health interventions.

Background and Rationale

Child undernutrition remains a large problem in developing countries with substantial adverse sequelae (Black 2008, Victora 2008).  It develops during the first two years of life, when mean weight-for-age and length-for-age Z-scores (WAZ and LAZ, respectively) of children living in Africa and Asia plunge to about –2.0 followed by little or no recovery (Victora 2010).

Under the plausible assumption that children grow poorly because they don’t eat enough of the right foods, enormous research effort has focused on identifying dietary solutions.  Numerous studies have tested a myriad of nutrient-dense foods and supplements, nutrition education interventions, and infant feeding behavioral-change strategies.  A recent review of 38 of the best of these studies revealed that most (but not all) achieved statistically significant growth effects: compared to controls, intervention children gained 0–760 g more weight (0.0 – 0.76 WAZ) and grew 0–1.7 cm taller (0.0 – 0.64 LAZ) by 12 to 24 months (Dewey 2008).   Enthusiasm is tempered, however, by the realization that the growth effect of even the most successful of these studies (~+0.7 Z) is equivalent to about one-third of the average deficit of Asian and African children (~–2.0 Z).   

Prevalent diarrhea has also been implicated.   In a pooled analysis of nine studies that together collected diarrhea and growth data on 1393 children, the odds of stunting at 24 mo increased multiplicatively by 2.5% per episode of diarrhea, and 25% of all stunting among 24-mo-old-children was attributable to having five or more episodes of diarrhea in the first two years of life (Checkley 2008). However, other authors have contended that the effect of diarrhea on permanent stunting is small because children grow at “catch-up” velocities between illness episodes (Briend 1990).  Hence, the relative contribution of diarrhea to undernutrition, and consequently, the potential impact that diarrhea control programs (i.e., sanitation/hygiene interventions) could have on growth has been unresolved.    The recent Lancet Undernutrition Series estimated that sanitation/hygiene interventions implemented with 99% coverage would reduce diarrhea incidence by 30%, which would in turn reduce prevalent stunting by a modest 2.4% (Bhutta 2008).

This study will test the hypothesis that a major cause of child undernutrition is Tropical or Environmental Enteropathy, more recently renamed Environmental Enteric Dysfunction (Keusch 2013) a subclinical condition of the small intestine caused by poor environmental sanitation and characterized by villous atrophy, crypt hyperplasia, increased permeability, inflammatory cell infiltrate, and modest malabsorption.8   Furthermore, the study will test the hypothesis that the primary pathway from sanitation/hygiene to child undernutrition is via EED rather than diarrhea.  If this is true, previous analyses may have substantially underestimated the effect of sanitation/hygiene on growth because the effect was modeled entirely through diarrhea, and sanitation/hygiene interventions may have been undervalued because they have been appraised primarily for their impact on diarrhea.  


About Zvitambo

The Zvitambo Institute for Maternal and Child Health Research is a multidisciplinary Zimbabwean organization that has developed and attracted expertise in various areas of biomedical and applied research and programming in the areas of maternal health, child health and growth, immunology, HIV/AIDS, nutrition, food security and livelihoods, WASH and counseling

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