Effects of improved complementary feeding and improved water, sanitation and hygiene on early child development among HIV-exposed children: substudy of a cluster randomised trial in rural Zimbabwe

BMJ Glob Health. 2020 Jan 13;5(1):e001718. doi: 10.1136/bmjgh-2019-001718. eCollection 2020.


Introduction: HIV-exposed uninfected children may be at risk of poor neurodevelopment. We aimed to test the impact of improved infant and young child feeding (IYCF) and improved water, sanitation and hygiene (WASH) on early child development (ECD) outcomes.

Methods: Sanitation Hygiene Infant Nutrition Efficacy was a cluster randomised 2×2 factorial trial in rural Zimbabwe ClinicalTrials.gov NCT01824940). Pregnant women were eligible if they lived in study clusters allocated to standard-of-care (SOC; 52 clusters); IYCF (20 g small-quantity lipid-based nutrient supplement/day from 6 to 18 months, complementary feeding counselling; 53 clusters); WASH (pit latrine, 2 hand-washing stations, liquid soap, chlorine, play space, hygiene counselling; 53 clusters) or IYCF +WASH (53 clusters). Participants and fieldworkers were not blinded. ECD was assessed at 24 months using the Malawi Developmental Assessment Tool (MDAT; assessing motor, cognitive, language and social skills); MacArthur Bates Communication Development Inventory (assessing vocabulary and grammar); A-not-B test (assessing object permanence) and a self-control task. Intention-to-treat analyses were stratified by maternal HIV status.

Results: Compared with SOC, children randomised to combined IYCF +WASH had higher total MDAT scores (mean difference +4.6; 95% CI 1.9 to 7.2) and MacArthur Bates vocabulary scores (+8.5 words; 95% CI 3.7 to 13.3), but there was no evidence of effects from IYCF or WASH alone. There was no evidence that that any intervention impacted object permanence or self-control.

Conclusions: Combining IYCF and WASH interventions significantly improved motor, language and cognitive development in HIV-exposed children.

Trial registration number: NCT01824940.

Keywords: HIV; HIV-exposed uninfected; complementary feeding; early child development; hand washing; safe drinking water; sanitation.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Child Development / physiology*
  • Child, Preschool
  • Drinking Water / standards*
  • Female
  • HIV Infections*
  • Humans
  • Hygiene / standards*
  • Infant
  • Infant Nutritional Physiological Phenomena*
  • Male
  • Pregnancy
  • Pregnancy Complications, Infectious
  • Rural Population
  • Sanitation
  • Water Supply
  • Zimbabwe


  • Drinking Water

Associated data

  • ClinicalTrials.gov/NCT01824940