Water, sanitation and hygiene interventions and the prevention and treatment of childhood acute malnutrition: A systematic review.

Undernutrition is more prevalent among children living in unsanitary environments with inadequate water, sanitation and hygiene (WASH). Despite good evidence for the effect of WASH on multiple infectious diseases, evidence for the effect of WASH interventions on childhood undernutrition is less well established, particularly for acute malnutrition. To assess the effectiveness of WASH interventions in preventing and treating acute childhood malnutrition, we performed electronic searches to identify relevant studies published between 1 January 2000 and 13 May 2019. We included studies assessing the effect of WASH on prevention and treatment of acute malnutrition in children under 5 years of age. Data were extracted by two independent reviewers. We included 26 articles of 599 identified references with a total of 43,083 participants. Twenty-five studies reported on the effect of WASH on prevention, and two studies reported its effect on treatment of acute malnutrition. Current evidence does not show consistent associations of WASH conditions and interventions with prevention of acute malnutrition or with the improvement of its treatment outcomes. Only two high-quality randomized controlled trials (RCTs) demonstrated that improved water quality during severe acute malnutrition treatment improved recovery outcomes but did not prevent relapse. Many of the interventions consisted of a package of WASH services, making impossible to attribute the effect to one specific component. This highlights the need for high-quality, rigorous intervention studies assessing the effects of WASH interventions specifically designed to prevent acute malnutrition or improve its treatment.