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
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
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DOI：
10.1371/journal.pmed.1002766
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发表时间：
2019-03-01
期刊：
影响因子：
15.8
通讯作者：
Prendergast, Andrew J.
中科院分区：
文献类型：
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作者：
Gladstone, Melissa J.;Chandna, Jaya;Prendergast, Andrew J.
背景 在全球范围内，近 2.5 亿儿童（占 5 岁以下儿童的 43%）由于贫困、发育迟缓和缺乏刺激而面临神经发育受损的风险。我们在津巴布韦农村参加卫生婴儿营养功效 (SHINE) 试验的儿童中，测试了改善水、环境卫生和个人卫生 (WASH) 以及改善婴幼儿喂养 (IYCF) 对儿童早期发育 (ECD) 的独立影响和综合影响。方法和结果 SHINE 是一项基于社区的整群随机 2x2 析因试验。共有 5,280 名孕妇参加了 211 个集群（定义为津巴布韦卫生和儿童保育部雇用的 1-4 名乡村卫生工作者 [VHW] 的服务区域）。分组被随机分配到标准护理、IYCF（从 6 至 18 个月大每天 20 克小量脂质营养补充剂加上辅食咨询）、WASH（通风改良坑式厕所、洗手站、氯、液体肥皂和游戏场）和 WASH + IYCF。主要结局是儿童年龄别身长 Z 评分和 18 个月大时的血红蛋白浓度。在 2016 年 3 月 1 日至 2017 年 4 月 30 日期间完成为期 18 个月的访视并年满 2 岁（102-112 周）的儿童有资格参加 ECD 子研究。我们预先规定，主要推论将从艾滋病毒阴性母亲所生孩子的调查结果中得出；本文介绍了这些结果。共有 1,655 名未接触 HIV 的儿童（其中符合资格的儿童的 64%）从 206 个群体中被招募到 ECD 子研究中，并在 2 岁时使用马拉维发育评估工具 (MDAT) 进行 ECD 评估，以评估粗大运动、精细运动、语言和社交技能；麦克阿瑟-贝茨交际发展量表（CDI）评估词汇和语法；用于评估对象持久性的 A-not-B 测试；和自我控制任务。对意向治疗人群的结果进行了分析。对于所有 ECD 结果，IYCF 和 WASH 干预措施之间不存在统计交互作用，因此我们通过比较 2 个 IYCF 组与 2 个非 IYCF 组以及 2 个 WASH 组与 2 个非 WASH 组来估计干预措施的效果。在未经调整的分析中，与非 IYCF 组相比，IYCF 组的平均 (95% CI) MDAT 总分稍高：1.35 (0.24, 2.46；p = 0.017)；这种差异在调整后的分析中并未持续存在：0.79（-0.22，1.68；p = 0.057）。没有证据表明 IYCF 干预对 CDI、A-not-B 或自我控制测试有影响。与非 WASH 组的儿童相比，WASH 组的儿童在 MDAT、A-not-B 或自我对照测试中的平均分数没有差异；在未经调整的分析中，平均 CDI 得分没有差异（0.99 [95% CI -1.18, 3.17]），但在调整分析中，WASH 组儿童的平均 CDI 得分较高（1.81 [0.01, 3.61]）。该研究的主要局限性是子研究招募的具体时间窗口，这意味着并非主要试验中的所有儿童都被纳入。 结论 我们发现几乎没有证据表明 SHINE 中实施的 IYCF 和 WASH 干预措施对 2 岁儿童发育产生了临床上重要的改善。可能需要直接针对神经发育（例如早期刺激）或更全面地解决神经发育的多因素性质的干预措施，以支持弱势儿童的健康发展。
Background Globally, 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 findings SHINE was a cluster-randomized community-based 2x2 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 We found little evidence that the IYCF and WASH interventions implemented in SHINE caused clinically important improvements in child development at 2 years of age. Interventions that directly target neurodevelopment (e.g., early stimulation) or that more comprehensively address the multifactorial nature of neurodevelopment may be required to support healthy development of vulnerable children.