Improving child development 

A new CDC handwashing study shows promising results 

National Center for Emerging and Zoonotic Infectious Diseases 

Division of Foodborne, Waterborne, and Enteric Diseases 

“...more than 200 

million children under 

5 years fail to reach 

their potential in 

cognitive development 

because of poverty, 

poor health and 

nutrition, and deficient 

care.” 

Sally Grantham-McGregor and 

colleagues, Lancet 369:60, 2007.

http://www.cdc.gov/healthywater/global/index.html 

Handwashing can help prevent diarrhea and pneumonia, two 

of the leading causes of death in children around the world.

Sanitation and hygiene are critical to health. 

Diarrheal diseases are common and largely preventable. Children are at particular 

risk for diarrhea and other diseases related to poor water, sanitation, and hygiene. 

Proper hygiene education is a critical step in reducing illness and death from 

diarrheal disease. In 2003, the Centers for Disease Control and Prevention (CDC) 

studied whether good hygiene can prevent diarrhea in young children. Some 

children in the study were given intensive handwashing promotion for 9 months, 

and others were not. Children whose families received soap for their handwashing 

stations and education about handwashing experienced approximately half as 

much diarrhea as children in a control group during the first 2 1/2 years of their 

lives, a critical time in their development.

What does handwashing have to do with healthy 

child development? 

The same children who participated in the 2003 study were followed up in 2009. In 

addition to having had less diarrhea, the children who got handwashing promotion 

also scored better in a detailed test of their development when they were 5–7 years 

old. These findings suggest that handwashing promotion could be an important 

strategy for improving child welfare. 

Heavy diarrhea or intestinal parasite loads in early childhood have been linked to 

delays in development. However, proper handwashing before meals and after 

going to the toilet can lower exposure to germs. This can lessen the chances of 

illness and chronic inflammation—leading to better nutrition intake, more energy 

available for growth and development, and better attendance at school. 

Important next steps

Transferring these findings to benefit the general public depends on strong 

partnerships and collaboration. In 2012, CDC presented these findings to 6,000 

pediatricians at a meeting of the Pediatric Academic Societies and to a publicprivate partnership for handwashing with soap. 

The challenge? To replicate these results in other settings and learn more about 

why handwashing had this sort of positive health effect in children. 

What is needed? More robust data to understand how handwashing can work to 

improve children’s health and development—whether by decreasing exposure to 

germs, increasing parent-child interactions, or both. Meanwhile, increased 

handwashing advocacy can be beneficial to greater segments of society. 
Soap + water = Cleaner bill of health and disease prevention in children

“There can be no sharper message 

to proponents of maternal and 

child health—that acting early in a 

child’s life reaps the highest reward 

both for individuals and societies.”

The Lancet, 378:1276, 2011

Proper handwashing in children: A call to action 

http://www.cdc.gov/healthywater/global/index.html 

Children who got handwashing promotion 

reached developmental milestones 6 months 

earlier than those who did not. 

Children whose families were exposed to nine months of a 

handwashing promotion tended to score better across five 

areas of development: 

Cognitive (skills and abilities commonly thought of as mental or 

intellectual, with the exception of language and communication 

skills)—Examples include finding hidden items in a complex picture, 

recalling facts from a story, and memorizing lines from books, TV 

shows, or songs. 

Communication (how effectively a child receives and expresses 

information and ideas)—Examples include responding to “who” or 

“what” questions, associating pictures with words, and identifying 

family members or pets when named. 

Motor (ability to control and use the large and small muscles of the 

body)—Examples include throwing a ball, hopping on one foot, and 

stacking cubes. 

Personal-social (abilities that allow a child to engage in meaningful 

interaction with adults and peers and to develop a self-concept and 

sense of a social role)—Examples include sharing toys, expressing 

emotions, and showing pride in accomplishments. 

Adaptive (ability to use information and skills from four other 

domains above)—Examples include using eating and drinking 

utensils, dressing themselves, washing their hands, and blowing 

their noses. 

Expand education to families and caretakers across society so that 

all children can obtain the health benefits from proper 

handwashing, and society can obtain the productivity benefits of a 

healthier population. This is a low-technology and accessible 

practice that can go hand-in-hand with other programs to promote 

child well-being, such as nutritional support and parenting 

education.

Bowen A, Agboatwalla M, Luby S, Tobery T, Ayers T, Hoekstra R. Association between 

intensive handwashing and child development in Karachi, Pakistan: A cluster controlled trial. 

Arch Pediatr Adolesc Med. 2012 Sep; [Epub ahead of print]