The influence of water, sanitation and hygiene and feeding practices on growth status and antibiotic resistance in infants aged 0-6 months in Dzimauli rural villages

Abstract

Malnutrition and antibiotic resistance remain critical and interconnected public health challenges in low- and middle-income countries, particularly during early infancy. This study explored the influence of water, sanitation and hygiene practices and feeding practices on growth status and antibiotic resistance in infants aged 0-6 months in the Dzimauli rural villages, Limpopo Province, South Africa. A prospective cohort design was used, involving 156 mother-infant pairs who were followed monthly from birth to six months. Data were collected using structured questionnaires assessing socio-demographic characteristics, water, sanitation, and hygiene practices, and feeding practices, alongside monthly anthropometric measurements and stool sample analyses to determine antibiotic resistance patterns in Escherichia coli. Generalised estimating equations were used to examine associations between water, sanitation and hygiene practices and growth outcomes, while multivariable logistic regression identified factors associated with multidrug resistance. Ethical approval was obtained from relevant university committees and provincial authorities, and written informed consent was secured from all participants, with confidentiality maintained through coded data and secure storage. Results showed that exclusive breastfeeding practices declined sharply from 71.0% in month one to 2.0% by month six. Although most infants had normal growth indicators, progressive declines in length-for-age z-scores and weight-for-age z-scores were observed over time. After adjustment, the water, sanitation and hygiene practices were not significantly associated with growth outcomes, despite temporal growth faltering. High resistance to tetracycline and cefepime (70.9%) was observed, and multidrug resistance was detected in 23.6% of infants. No independent predictors of multidrug resistance were identified in adjusted models, partly due to limited sample size and sparse data. The study highlights the coexistence of growth faltering and early-life antibiotic resistance in rural settings and underscores the need for integrated interventions that strengthen water, sanitation and hygiene practices infrastructure, promote optimal infant feeding practices, and support antimicrobial stewardship to improve child health outcomes.