The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement.

BACKGROUND: Three large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations' Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners. MAIN BODY: Here we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health. CONCLUSION: These results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that - in any context - a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.

Preconception maternal nutrition: a multi-site randomized controlled trial.

BACKGROUND: Research directed to optimizing maternal nutrition commencing prior to conception remains very limited, despite suggestive evidence of its importance in addition to ensuring an optimal nutrition environment in the periconceptional period and throughout the first trimester of pregnancy. METHODS/STUDY DESIGN: This is an individually randomized controlled trial of the impact on birth length (primary outcome) of the time at which a maternal nutrition intervention is commenced: Arm 1: ≥ 3 mo preconception vs. Arm 2: 12-14 wk gestation vs. Arm 3: none.192 (derived from 480) randomized mothers and living offspring in each arm in each of four research sites (Guatemala, India, Pakistan, Democratic Republic of the Congo). The intervention is a daily 20 g lipid-based (118 kcal) multi-micronutient (MMN) supplement. Women randomized to receive this intervention with body mass index (BMI) <20 or whose gestational weight gain is low will receive an additional 300 kcal/d as a balanced energy-protein supplement. Researchers will visit homes biweekly to deliver intervention and monitor compliance, pregnancy status and morbidity; ensure prenatal and delivery care; and promote breast feeding. The primary outcome is birth length. Secondary outcomes include: fetal length at 12 and 34 wk; incidence of low birth weight (LBW); neonatal/infant anthropometry 0-6 mo of age; infectious disease morbidity; maternal, fetal, newborn, and infant epigenetics; maternal and infant nutritional status; maternal and infant microbiome; gut inflammatory biomarkers and bioactive and nutritive compounds in breast milk. The primary analysis will compare birth Length-for-Age Z-score (LAZ) among trial arms (independently for each site, estimated effect size: 0.35). Additional statistical analyses will examine the secondary outcomes and a pooled analysis of data from all sites. DISCUSSION: Positive results of this trial will support a paradigm shift in attention to nutrition of all females of child-bearing age. TRIAL REGISTRATION: ClinicalTrials.gov NCT01883193.

Promoting healthy growth: what are the priorities for research and action?

Healthy growth from conception through the first 2 y of life is the foundation for adequate organ formation and function, a strong immune system, physical health, and neurological and cognitive development. Recent studies identified several low-cost interventions to address undernutrition during this age period and noted the lower returns on investment of intervening after this critical period. Although these interventions should be implemented widely, it is recognized that existing nutrition solutions, even if universally applied, would only avert a minority fraction of the estimated death and disability due to undernutrition. This paper reviews some of the knowledge and learning needed to close this "impact gap." Five areas are prioritized for future research: 1) study healthy growth from a lifecycle perspective, because maternal, fetal, and newborn outcomes are connected; 2) understand why growth faltering begins so early in breast-fed infants in the developing world; 3) apply new tools and technologies to study long-recognized problems such as the interaction between nutrition and infection; 4) explore new hypotheses for understanding nutrient assimilation and use to discover and develop intervention leads; and 5) understand the role of the environment in healthy growth and the potential synergistic benefits of multi-sectoral interventions. Policymakers are urged to invest in nutrition-specific and -sensitive interventions to promote healthy growth from conception through the first 2 y of life because of their immediate and long-term health and development benefits.