1. The Baby and the Bathwater: WASH, Nutrition and Rubber Ducks Renuka Bery, WASHplus/FHI 360 Melissa Kelly, Child Fund Merri Weinger, USAID

2. Objective of This Session To share the evidence and the global conversation about integrated programming in WASH, nutrition and ECD To engage new energy and talent in promoting flowers to bloom everywhere across the WASH-nutrition-early child development nexus

3. Exercise: Growing Your Child Beyond the Duckies

4. You are part of a family in rural Africa or Asia….. You have been learning about ways to keep your family healthy….

5. With one or two of your neighbors in this session, take a blank piece of paper …. - List the daily activities of a typical woman on a rural homestead. You have 5 minutes… Make assumptions and go! Don’t worry about details or ‘getting it perfect’…

6. As you read through the activities of the typical woman, identify ‘places’ where the young child will be.

7. Building the Case for Integration: The 3 Legged Stool

8. Safe Storage & Treatment of Water Handwashing Safe Feces Disposal Focus on WASH behaviors for Diarrhea Disease Reduction…. 21% 30% ++ 43% 30-50% Review of the Evidence

9. Undernutrition Diarrhea Interrelationship of Diarrhea & Malnutrition Children with diarrhea tend to eat less With diarrhea, nutrients from food are not well-absorbed Undernourished children are more susceptible to diarrhea 9

10. KK Saha et al (ICDDR,B), Food and Nutrition Bulletin 2009 Most rapid decline during 3-15 months << “Normal” Most damage occurs during complementary feeding age

11. Month 20072008 2009 Prevalence of Diarrhea among Children < 5 years by observed handwashing before preparing food SHEWA-B, Rural Bangladesh PLoS Med, 2011;8(6): e1001052. 12.5%

12. Month 2007 20082009 12.5% 8.3% PLoS Med, 2011;8(6): e1001052. Prevalence of Diarrhea among Children < 5 years by observed handwashing before preparing food SHEWA-B, Rural Bangladesh

13. Month 20072008 2009 12.5% 8.3% 6.9% PLoS Med, 2011;8(6): e1001052. Prevalence of Diarrhea among Children < 5 years by observed handwashing before preparing food SHEWA-B, Rural Bangladesh

14. Sanitation alone explains 54% of international variation in child height - GDP only explains 29% Source: Each data point is a collapsed DHS survey round (country-year), proportional to population. Spears (2012) www.riceinstitute.org #13 Open Defecation Accounts for Much of Excess Stunting

15. Cause #1: Malnourished Mother Cause #2: Poor Diet (inadequate weaning foods) Cause #3: Diarrhea What is causing all this stunting? …. But something else is going on…

16. However: Evidence exists that the effect of WASH interventions on linear growth is independent of its effect on diarrhea. In several studies, WASH had a bigger effect on growth than it did on diarrhea …. there is something else going on… Slides stolen from Cornell U Division of Nutritional Sciences, Laura Smith. R Stoltzfus, F Ngure, B Reid, G Pelto, M Mbuya, A Prendergast, J Humphrey

17. Ball exercise

18. Cause #4: The Environmental Enteropathy Hypothesis A subclinical condition of the small intestine, called environmental enteropathy (EE) Characterized by: – Flattening of the villi of the gut, reducing its surface area – Thickening of the surface through which nutrients must be absorbed – Increased permeability to large molecules and cells (microbes) Likely causes: – Too many microbes in the gut – Effects of toxins on the gut Slides borrowed from Cornell U Division of Nutritional Sciences, Laura Smith. R Stoltzfus, F Ngure, B Reid, G Pelto, M Mbuya, A Prendergast, J Humphrey

19. Most frequent 38 times in 6 hours 75% visibly dirty Dirtiest Soil (3 ate avg 11 bites) chicken faeces, stones Slides borrowed from Cornell U Division of Nutritional Sciences, Laura Smith. R Stoltzfus, F Ngure, B Reid, G Pelto, M Mbuya, A Prendergast, J Humphrey

20. % HH with E coli + sample E coil/ Per gram Average E Coli Per Day Infant Food 0%0 0 Drinking Water 54%2 800 Soil in laundry area 60-80%70 1,400 Chicken feces 100%10,000,000 Clearly, kids must stop eating dirt and chicken poop!

21. Eating dirt and more Laundry Water Nappy Handling Protective Play Space for babies!

22. Family Support School and Community Services Child Development: Multiple Contributing Factors Health Nutrition Learning Opportunities Sensitive/ Responsive Caregiving Social Protection Protection from Stress/ Harm Slides taken from Maureen Black’s CFN Presentation

23. Family Support School and Community Services Child Development: Multiple Contributing Factors Health Nutrition Learning Opportunities Sensitive/ Responsive Caregiving Social Protection Protection from Stress/ Harm Nutrition is necessary for child development, but not sufficient! Slides taken from Maureen Black’s CFN Presentation

25. Target of Interventions Prenatal – Prevent Toxic stress/LBW/Prematurity Infancy – Breastfeeding, complementary feeding – Responsive Parenting – Opportunities for early learning – Routines to promote regulation – Family support Kramer et al., 2008; 2007 & 2011 Lancet series on Child Development Slides taken from Maureen Black’s CFN Presentation

26. Not Just about Child Survival … and not just about more / better food Key period for formation of the brain, laying the foundation for development of cognitive, motor and socio-emotional skills Adequate nutrition for pregnant women and infants is necessary for ‘normal’ brain development Lack of micronutrients especially critical to optimal infant cognitive and motor development. Children with restricted development in early life are at risk – later neuropsychological problems, – poor school achievement, – early school drop out, – low-skilled employment and lower wage earnings, – poor care of their own children Some of damage is irreparable if not addressed before age 2** Contributes to the intergenerational transmission of poverty

27. Exercise Part 2: Use your knowledge and experience and the new information you have learned today to identify those places or situations that will put a child in danger. - Brainstorm ways to overcome these dangers. - Discuss challenges that may hinder progress. You have 10 minutes

28. Share ideas in plenary….

29. The Closing Session will begin at 4pm in the Grand Ballroom. Closing remarks will be followed by a 30-minute social gathering (refreshments will be served). Come meet new people and discuss the highlights of the day! Please fill out an evaluation by going to this session’s page on your mobile app OR by filling out a paper evaluation in the back of the room. Thank you!