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National Institute of Environmental Health Sciences

Your Environment. Your Health.

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Recognizing the Role of Water Insecurity in Infant Undernutrition

By Mali Velasco

woman queing water

A woman in Kenya carries a can to a water source where others wait for clean water. Long waiting times for water can take away time from feeding and caring for infants.
(Photo courtesy of Patrick Mbullo, Study Site PI for Seme, Kenya)

A recent study, funded in part by NIEHS, identifies how water insecurity affects infant feeding at the household level and suggests a research agenda to understand how water security can be leveraged to improve global child nutrition and health. The study uses data from the Household Water Insecurity and Experiences Study (HWISE).

The Household Water Insecurity Experiences – Research Coordination Network (HWISE-RCN)

Funded by the National Science Foundation, HWISE is a global community of academics and practitioners studying and working in the interdisciplinary field of water insecurity. The HWISE consortium developed the first cross-culturally validated scale to assess water insecurity at the household level to help assess how problems with water impact health and well-being across disparate and ecological settings. This HWISE scale is being implemented in the Gallup World Poll as an indicator for research, programming, and policy.

Household water insecurity, or the “inability to access and benefit from reliable and safe water for well-being and healthy life,” has been linked to food insecurity and malnutrition.

“There are several studies about how poor water quality can lead to infections, malnutrition, and poor infant health, but we were interested in understanding other impacts, such as the effects of water insecurity on breastfeeding and complementary feeding, as well as indirect impacts through caregiving,” said lead study author Roseanne Schuster, Ph.D., director of Special Initiatives for Global Health and International Development at Arizona State University’s School of Human Evolution and Social Change.

Around the world, 160 million children experience stunting and chronic malnutrition as a result of inadequate access to safe water and sanitation. Estimates suggest that 4 billion people face severe water scarcity for at least one month every year globally. This figure is likely an underestimation given challenges with water infrastructure and access, increased flooding and droughts, and poor water quality that exacerbate the problem of water insecurity. Schuster says that the number of people experiencing water insecurity, and the challenges they are facing, will likely be intensified by climate change, and the impact of water insecurity in infant feeding needs to be considered as a component of child undernutrition research.

To understand the link between water insecurity and infant feeding, the team interviewed more than 3,500 caregivers from 19 sites in 16 low- and middle-income countries. They grouped responses into four domains – breastfeeding, non-breastmilk feeding, caregiver capabilities, and infant health – and identified themes that were common across sites and cultures.

Non-breastmilk feeding was the most frequently and commonly cited domain, followed by infant health, caregiver capabilities, and breastfeeding.

Woman collecting water for boiling

A woman in Nepal collecting water for boiling. Women are typically household water managers and daily water management activities can interrupt child feeding and care activities.
(Photo courtesy of Ashley Hagaman, Study Site PI for Kathmandu, Nepal)

“Our most critical finding for infant feeding, that was endorsed in nearly all study sites, is that water insecurity is perceived to affect the quantity, quality, and diversity of foods that infants are fed,” said Schuster.

Respondents reported that water insecurity led them to feed infants unwashed foods, prepare food with dirty water, give infants less food, and replace a diverse diet with options that do not require as much water for preparation.

Across all 19 sites, respondents identified a relationship between water insecurity and infant health. They linked water insecurity to infant undernutrition, hunger, and dehydration. They also made connections between water insecurity and infectious diseases, diarrhea, and dysentery, which could lead to infant death.

Breastfeeding was the least discussed domain among respondents, mentioned in just 12 of 19 sites. For healthy growth and development, the World Health Organization (WHO) recommends that for the first six months, mothers exclusively breastfeed their infants, adding nutritious complementary foods thereafter. However, some respondents reported having to substitute breastmilk for solid foods when water was contaminated or there was insufficient water for cooking.

Other reported breastfeeding challenges linked to water insecurity include decreased breastmilk production resulting from a poor diet and potentially exposing the infant to pathogens when there is not enough water to wash the breast before feeding.

Respondents also made connections between water insecurity and caregiver capabilities, which may have indirect effects on infant feeding and health. They reported that collecting water resulted in missed or delayed feeding times.

“Perhaps our most surprising finding was how water insecurity affects caregiver capabilities. Women around the world are typically child caregivers and manage household water,” explained Schuster. “Time spent on collecting and managing household water take time away from women feeding or caring for children, and this could have indirect effects on infant health.”

Household water insecurity

Water insecurity affects infant feeding and health through many pathways. ↑ indicates increase, ↓ indicates decrease, and △ indicates depends on.
(Photo courtesy of

Implications for Global Environmental Health Research

With their findings, the team created a framework to help researchers understand the many pathways by which water insecurity affects infant feeding and health. The team recommends that future research examine the root causes and indirect consequences of water insecurity using a biocultural approach. They also recommend researchers assess the impact of water insecurity on health indicators such as dehydration and body measurements.

With a team of collaborators, Schuster is currently looking at how water insecurity is linked with poor child dietary diversity and stunting. “There is still a lot of work to do to understand the implications of water insecurity on child health and caregiver capabilities around the world,” said Schuster. “I’m excited for others to think about how they can incorporate water insecurity into their ongoing research.”

October Is Children’s Environmental Health Month

Children today face many challenges linked to environmental factors. The Network of NIEHS-WHO Collaborating Centre (WHOCC) for Children’s Environmental Health is undertaking efforts to better understand how the environment affects global children’s health and to promote children’s well-being through healthy environments. Through the Network, NIEHS works with other WHO Collaborating Centres and leading research institutions to build evidence and capacity, coordinate collaborative research, raise awareness of children’s environmental health issues, and develop interventions to reduce childhood environmental exposures.