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• W3025531913 abstract "The objective of the study was to investigate potential risk factors for growth faltering among children under 5 years of age. We conducted a prospective cohort study of 553 children under 5 years from diarrhoea patient households in urban Dhaka, Bangladesh. Height and weight measurements were obtained at baseline and at a 12-month follow-up. Caregivers of young children were administered a monthly questionnaire on household sociodemographic characteristics and hygiene practices. Children with caregiver reports of mouthing soil at the majority of household visits had a significant reduction in their height-for-age z-scores (HAZ) from baseline to the 12-month follow-up (ΔHAZ: −0.28 (95% confidence interval (CI): −0.51, −0.05)). A significant reduction in HAZ was also observed for children in households with animals in their sleeping space (ΔHAZ: −0.37 (95% CI: −0.71, −0.04)). These findings provide further evidence to support the hypothesis that child mouthing of soil and the presence of animals in the child’s sleeping space are potential risk factors for growth faltering among young children. Interventions are urgently needed to provide clean play and sleeping spaces for young children to reduce exposure to faecal pathogens through child mouthing. L'objectif de l'étude était d'examiner les facteurs de risque potentiels de retard de croissance chez les enfants de moins de 5 ans. Nous avons mené une étude de cohorte prospective sur 553 enfants de moins de 5 ans provenant de ménages avec des patients diarrhéiques dans la ville de Dhaka, au Bangladesh. Les mesures de taille et de poids ont été obtenues au départ et à 12 mois de suivi. Les personnes s’occupant de jeunes enfants (les gardiens) ont reçu un questionnaire mensuel sur les caractéristiques sociodémographiques des ménages et les pratiques d'hygiène. Les enfants pour lesquels les gardiens ont déclaré qu'ils mâchouillaient de la terre lors de la majorité des visites à domicile présentaient une diminution du score Z de taille pour l’âge (TAZ) de manière significative de l'âge de référence au 12 mois de suivi (ΔTAZ −0,28 (intervalle de confiance (IC) à 95%: −0,51, −0,05)). Une réduction significative des TAZ a également été observée pour les enfants des ménages ayant des animaux dans leur espace de couchage (ΔTAZ −0,37 (IC95%: −0,71, −0,04)). Ces résultats apportent des données supplémentaires pour appuyer l'hypothèse selon laquelle le fait que l'enfant mâchouille de la terre et la présence d'animaux dans son espace de couchage sont des facteurs de risque potentiels de retard de croissance chez les jeunes enfants. Des interventions sont urgemment nécessaires pour fournir des espaces de jeu et de sommeil sains aux jeunes enfants afin de réduire l'exposition aux agents pathogènes fécaux par le mâchouillement des enfants. In 2018, there were estimated to be 149 million children <5 years of age that were stunted globally [1]. In Bangladesh, 36% of children <5 years are estimated to be stunted [2]. Growth faltering in young children is associated with an increased risk of mortality and impaired cognitive development [3-5]. Previous studies have identified multiple risk factors for impaired child growth including unimproved sanitation facilities, crowded living spaces, caregiver hand hygiene and lack of water treatment [6-10]. Furthermore, there is an emerging literature demonstrating the importance of non-dietary exposure routes to faecal pathogens among young children such as child mouthing of contaminated fomites and contact with domestic animal [11-16]. However, these studies have been conducted mostly in rural settings, and there are very few interventions targeting this exposure route to faecal pathogens [11, 12, 17, 18]. These findings highlight the urgent need for water, sanitation and hygiene (WASH) interventions to prevent impaired growth among susceptible paediatric populations. Diarrhoeal diseases continue to be a major cause of mortality among young children globally, causing 500 000 deaths annually [19]. Chronic enteric infections can cause micronutrient deficiencies which can impair child immunity and cause recurrent infections and poor growth among young children [6, 20-22]. Furthermore, frequent enteric infections can cause environmental enteropathy (EE), a condition also known as tropical enteropathy or environmental enteric dysfunction, which is associated with impaired growth in young children [11, 23-26]. Environmental enteropathy is characterised by abnormal intestinal morphology, increased inflammation and reduced intestinal barrier function [27-35]. This condition occurs from unhygienic environments resulting in repeated exposure to faecal pathogens [23]. Household contacts of diarrhoea patients, including young children, are at a higher risk of becoming infected with enteric pathogens (>100 times for cholera) during the first 7 days after the index diarrhoea patient seeks care from a health facility compared with the general population [36-38]. This is likely because of a shared contaminated water source and poor hygiene practices in the home [39, 40]. However, despite this high risk, there have been few interventions targeting this susceptible population. To develop a standard of care for this high-risk population, our research group developed the Cholera Hospital-Based Intervention for 7 days (CHoBI7). ‘Chobi’ means ‘picture’ in Bangla for the pictorial modules delivered as part of the intervention. This health facility-initiated WASH intervention focuses on promoting handwashing with soap and water treatment to diarrhoea patients and their household members during the one-week high-risk period after the patient is admitted to the health facility. Delivery of the CHoBI7 intervention resulted in a 47% reduction in cholera infections, and a significant reduction in symptomatic cholera during the one week high-risk period in our previous randomised controlled trial (RCT) [41]. Furthermore, we observed sustained increases in handwashing with soap and stored drinking water quality 12 months after the delivery of this one-week intervention [41, 42]. Building on this work, we are currently developing and testing scalable approaches for delivering the CHoBI7 intervention to diarrhoea patient households using mobile health (mHealth) [43]. In this prospective cohort study, we investigated individual, demographic, and environmental risk factors for growth faltering among young children in diarrhoea patient households in urban Dhaka, Bangladesh. The objective of the cohort study was to identify risk factors for impaired growth among young children in an urban setting that could inform future CHoBI7 intervention development and refinement. We hypothesised that child mouthing behaviours and exposure to domestic animals would be important risk factors for impaired growth in this population. This study was nested within the RCT of the CHoBI7 WASH mHealth program [44]. The CHoBI7 program evaluated in this RCT did not include the promotion of safe disposal of child or animal faeces or other methods of separating children from animal faeces in their environment. Details of the CHoBI7 mHealth program are published elsewhere [43]. Diarrhoeal patients were screened and enrolled at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and Mugda General Hospital (government hospital) in Dhaka, Bangladesh from December 2016 to April 2018. The eligibility criteria for diarrhoea patients were the following: patients had to (1) have 3 or more loose stools over the past 24 hours; (2) plan to reside in Dhaka for the next 12 months; (3) not have a basin for running water in their home (mostly those residing in slum areas of Dhaka); (4) have a child under five years of age in their household (including themselves); and (5) have a working mobile phone in the household. Once diarrhoea patients were enrolled, we identified and enrolled their corresponding household members. The eligibility criteria for household members were the following: (1) shared the same cooking pot and resided in the same home with the diarrhoea patient for the previous three days; and (2) plan to reside with the diarrhoea patient for the next 12 months. Diarrhoeal patients were enrolled Saturday through Thursday each week. All household members were enrolled within 36 hours of patient enrolment. To investigate environmental, demographic and behavioural risk factors for child growth, we compared individual and household level characteristics among a cohort of 553 children under 5 years enrolled in the RCT of CHoBI7 mHealth program. Research assistants trained in standardised anthropometry measured the weight once and height three times for each enrolled child under 5 years at baseline and at a 12-month follow-up. Average height and weight measurements were used to calculate z-scores according to the WHO child growth standards [45]. Height-for-age z-scores (HAZ), weight-for-age z-scores (WAZ) and weight-for-height/length z-scores (WHLZ) were calculated. These growth measures allowed us to determine how selected risk factors impacted the growth trajectories of study children. This builds upon previous studies relying solely on the binary cut-offs typically used to categorise child growth (e.g. stunting, underweight and wasting) by allowing us to quantify the impact of each risk factor on child growth. Caregivers of children <5 years were administered a questionnaire on sociodemographic factors at baseline including household literacy, latrine type, and refrigerator, television and animal ownership. In addition, caregivers were administered a monthly hygiene questionnaire on child mouthing practices and child faeces disposal practices. To develop an indicator that combined both the presence and frequency of hygiene behaviours, we summarised child mouthing and child faeces disposal measures over the study period. The primary outcome of this study was child growth defined by the WHO child growth standards. The change in the following growth measures from baseline to the 12-month follow-up among children <5 years of age were used to assess child growth: (1) WAZ, (2) HAZ, and (3) WHLZ. Written informed consent was obtained from all adult study participants before enrolment. Written assent was obtained from child participants (12–17 years old), and parental permission was obtained for children <18 years of age. All study procedures were approved by the research review and ethical review committee of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health. This is an exploratory analysis. The primary outcomes of this study were the change in HAZ, WAZ, WHLZ from baseline to the 12-month follow-up. The predictors were previously identified as environmental, demographic and behavioural risk factors for child growth [6, 7, 11]. Linear regression analysis was performed using generalised estimating equations to account for clustering at the household level using robust variance estimators to approximate 95% confidence intervals for the association between covariates and the change in child growth. Models were adjusted for study arm, refrigerator ownership, sleeping room, roof type, wall type, baseline age, baseline z-score and whether the index diarrhoea patient was a child under 5 years. All analyses described above were performed using Stata software version 13 (Stata Corp, College Station, Texas, USA). Five hundred and fifty three children from 506 households that had anthropometric measurements at baseline and the 12-month follow-up were included in this analysis, 78% (434/553) of these children were index diarrhoea patients. The mean baseline age was 13.8 ± 11.0 months (mean ± standard deviation (SD), range: 1–47). Forty two percent (233/553) of children were female, and the average number of individuals living in a household was 4.6 ± 1.5 (mean ± SD). Forty eight percent (268/553) of children resided in households reporting refrigerator ownership and 88% (487/553) resided in households with at least one household member who could read and write. Seventeen percent (93/547) of children resided in households reporting animal ownership, and 10% (53/547) of children had animals present in their sleeping spaces. Ten percent (52/547) of children lived in households that owned chickens, 9% (48/547) owned birds, 1% (7/547) owned cats, and 0.4% (2/547) owned dogs. Twenty four percent (133/553) of children were reported by caregivers to put soil in their mouth, and 65% (359/553) to put a visibly dirty object in their mouth during the majority of surveillance visits. Seven percent (36/547) of children resided in households with an unimproved latrine (Table 1). Change in Weight-for-Age Z-score Change in Height-for-Age Z-score Children that had caregiver reports of mouthing of soil at the majority of household visits had a significant reduction in HAZ from baseline to the 12-month follow-up (ΔHAZ −0.28 (95% confidence interval (CI): −0.51, −0.05). Children that had animals in their sleeping space also had a significant reduction in HAZ (−0.37 (95% CI: −0.71, −0.04)). Children in households where unimproved latrines were used had a significant reduction in WHLZ (−0.41 (95% (CI): −0.82, −0.00004). Children in households that owned a refrigerator had a significant increase in HAZ (0.21 (95% CI: 0.002, 0.42)), WHLZ (0.32 (95% CI: 0.10, 0.53)) and WAZ (0.30 (95% CI: 0.13, 0.48)). Having at least one household member that could read and write was also associated with a significant increase in HAZ (0.38, 95% CI: 0.07, 0.69) (Table 1). In this longitudinal study, we investigated risk factors for impaired growth among children <5 years of age in urban Dhaka, Bangladesh. We found child mouthing of soil and animals being present in the child’s sleeping space to be important risk factors for impaired linear growth among young children. We also observed that an unimproved latrine in the household was an important risk factor for child growth. These findings emphasise the urgent need for interventions targeting child mouthing of contaminated fomites, exposure to animals in the child’s sleeping space and improved latrines to reduce exposure to faecal pathogens for susceptible paediatric populations. The significant association we observed between child mouthing of soil and impaired child growth is consistent with our previous findings from rural Bangladesh [6]. The strength of the association was also similar, −0.28 ΔHAZ in the current study vs. −0.31 ΔHAZ in our previous study. In our previous work, we found that child mouthing of soil was also associated with elevated faecal markers of environmental enteropathy, an association we did not investigate in the current study [24]. Child mouthing is a normal part of child development where children learn from their environment by using their hands and mouth [46-49]. However, in environments where faecal contamination is high, child mouthing puts young children at high risk for exposure to faecal pathogens and enteric infections [50, 51]. Previous studies have found that child mouthing of soil is associated with diarrhoea and helminth infections [52, 53]. Future studies are needed to identify how to reduce exposure to faecal pathogens from child mouthing behaviors among young children during this important stage of child development. Consistent with previous studies, we found that the presence of an animal in the child’s sleeping space was associated with impaired linear growth among young children. This is the first study to our knowledge to find this association in an urban setting. In our previous study in rural Bangladesh, we found that children with animal corrals in their sleeping room had significantly elevated levels of faecal markers of environmental enteropathy and an increased odds of stunting [11]. Weisz et al. [32] conducted in rural Malawi found that sleeping with animals was also negatively associated with linear growth among preschool-age children. Previous studies have demonstrated that contact with domestic animals can be a transmission route for enteric pathogens for susceptible paediatric populations [54-57]. In urban Dhaka, animals such as birds are often kept as pets or kept by vendors to sell as pets. In slum areas of Dhaka, families are often confined to a single room, which increases their contact with domestic animals in their sleeping space. We suspect that keeping animals in the sleeping space of the home resulted in increased exposure to enteric pathogens through increased direct contact with these animals and faecal contamination on the household floor from animal faeces. Interventions are needed to separate domestic animals, and their faeces from the sleeping spaces of young children. Consistent with previous findings in Ethiopia, we observed that unimproved latrines in households were associated with lower WHLZ in young children. In Ethiopia Cooten et al. [58] observed that children in households with access to an improved toilet facility had a 37% lower odds of being wasted relative to children in households with access to unimproved toilet facilities (AOR = 0.63, 95% CI [0.46, 0.86]). Previous studies have found unimproved latrines in households were associated with impaired linear growth in children, an association we did not observe in our study [59, 60]. Torlesse et al. in Indonesia observed that children under 2 years residing in households using unimproved latrine had over a three times higher odds of stunting [59]. In Ethiopia, Dearden et al. [60] found that not having an improved sanitation facility at one year of age resulted in a 60% increased risk of stunting. In our study area nearly all households shared a latrine with other households, so this may have diluted the impact of improved sanitation on linear child growth. Our study observed a strong association between ownership of a refrigerator and improved child growth for all growth measures. This finding is consistent with findings from Brazil and Nigeria, which found that ownership of a refrigerator was associated with improved linear growth [61, 62]. This finding is likely attributed to the purchasing power of the household, and thereby representative of their socioeconomic status; as well as a refrigerator contributing to the ability to perform improved food storage practices in the household thereby reducing the load of faecal contamination in stored food. In Bangladesh, refrigerator ownership has grown dramatically over the past 10 years [2]. This is likely because of the country’s rapidly increasing gross domestic product, and from companies manufacturing low-cost refrigerators that households can pay for in installments [63, 64]. We also observed that having someone in the household who can read and write was associated with increased linear growth. This is consistent with findings from a recent study of 39 countries which found that maternal and paternal education was associated with improved linear growth [65]. This is likely representative of the educational level of study participants and a proxy measure of their socio-economic status. This study had some limitations. First, we did not include the analysis of stool samples for faecal markers of environmental enteropathy. Second, we did not include the analysis of stool samples for enteric pathogens. Third, we did not measure the micronutrient status of study children to determine how this was related their growth. Fourth, we relied on self-reported WASH indicators. This study also had several strengths. The first is the prospective design of the study over a 12-month period which allowed us to account for seasonality in our behavioural outcomes. The second was the monthly surveillance of child mouthing and child faeces disposal behaviours which allow us to gain a more robust measure of these behaviours. The third was anthropometric measurements being performed at baseline and at a 12 month follow-up, which allowed us to observe changes in child growth. These study findings provide further evidence to support the hypothesis that child mouthing of soil and the presence of animals in the child’s sleeping space are risk factors for impaired growth in young children. Furthermore, these results are consistent with previous studies that have shown that using an unimproved latrine is associated with impaired growth for susceptible paediatric populations. Interventions are needed to provide clean play and sleeping spaces for young children to reduce exposure to faecal pathogens through child mouthing behaviors. This research was supported by a USAID grant awarded to Johns Hopkins School of Public Health. We thank USAID for their support. We thank the study participants and the following individuals for their support with the implementation of this study: Professor Abul Khair Mohammad Shamsuzzaman, Professor Be-Nazir Ahmed, Fosiul Alam Nizame, Khobair Hossain, Jahed Masud, Ismat Minhaj Uddin, Rafiqul Islam, Maynul Hasan, SM. Arifur Rahman, Abdullah Al Morshed, Zakir Hossain, Kabir Hossain, Amal Sarker, Abul Bashar Sikder, Abdul Matin, Sadia Afrin Ananya, Lubna Tani, Farhana Ahmed, Tahera Taznen, Marufa Akter, Akhi Sultana, Nasrin Akter, Laki Das, Abdul Karim, Shirin Akter, Khan Ali Afsar and Wasim Ahmed Asif. We also thank hospital staff for their support. icddr,b acknowledges the governments of Bangladesh, Canada, Sweden and United Kingdom for providing core/unrestricted support." @default.
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• W3025531913 date "2020-07-18" @default.
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• W3025531913 title "Child mouthing of soil and presence of animals in child sleeping spaces are associated with growth faltering among young children in Dhaka, Bangladesh (CHoBI7 Program)" @default.
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• W3025531913 doi "https://doi.org/10.1111/tmi.13417" @default.
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