Aisha K. Yousafzai, Associate Professor, Department of Paediatrics and Child Health, Aga Khan University, Pakistan, and Mandana Arabi, Director, Business Platform for Nutrition Research, Global Alliance for Improved Nutrition (GAIN), Washington DC, USA
Inadequate nutrition and stimulation are key risk factors associated with poor development of children. This article first describes their prevalence and then explores the rationale for integrated and comprehensive approaches which combine interventions to mitigate these risks. It reviews the evidence that informs best practice in delivering integrated nutrition and stimulation interventions, and concludes with recommendations for practice, policy and research.
If children fail to get what they need – enough nutrition, nurturing, stimulation, and a sense of security – during the most critical years of early childhood, the impact on their lives and futures is enormous.
Anthony Lake (Executive Director, UNICEF) and Margaret Chan (Director-General, World Health Organization), 2014
As the period of the Millennium Development Goals (MDGs) draws to a close, we can reflect on the progress made for children and review the lessons learned to do better in the post-2015 era. Significant progress has been made for MDG 4 (reduce by two-thirds, between 1990 and 2015, the under-5 mortality rate): the number of child deaths has been reduced by half to approximately 6.3 million (Requejo and Bhutta, 2015). However, among those who survive, it is estimated that close to 200 million children fail to meet their developmental potential in their first five years, resulting in lower educational attainment, reduced economic productivity and poorer physical and mental health outcomes (Grantham-McGregor et al., 2007).
The post-2015 agenda will focus on sustainable development, and will require healthy, productive, creative, confident and capable citizens (United Nations, 2014). Therefore, early childhood interventions cannot focus on survival alone, but must also support and promote development of young children. The critical building blocks for children’s early development are adequate and appropriate nutrition; stable, responsive, and nurturing environments with learning opportunities; and safe, supportive physical environments. A bundle of nutrition, stimulation and care interventions is essential to help children get off to a good start, with the knowledge and competencies they need to compete in tomorrow’s world.
Biological and psychosocial risks that affect children’s early development include maternal, infant and young child malnutrition, intrauterine growth restriction, infections, lack of opportunities for learning and social interaction, exposure to environmental toxins, exposure to violence and maternal depression (Walker et al., 2007, 2011a). Exposure to these risks in the early years compromises the quality of brain development, which is shaped by continuous interactions between genes, environment and experience, and leaves long-term impacts on health and learning (see pages 70–73). For many children growing up in disadvantaged contexts, risks tend to co-occur and accumulate, further compromising early brain development and fostering inequalities (Shonkoff and Garner, 2012). Among the most significant risks that affect children’s early development are malnutrition and inadequate stimulation.
The global burden of malnutrition
Malnutrition, with a particular focus on the first 1000 days of life (conception to 2 years of age) is a risk factor for survival and development. The prevalence of overweight and obesity is increasing both for pregnant women and for children in the first five years of life with increased risks for maternal and infant mortality and morbidity, as well as poor health in later life. However, global attention is still focused on undernutrition, with widespread macronutrient and micronutrient deficiencies in low- and middle-income countries (LMICs). It is estimated that undernutrition encompassing fetal growth restrictions, suboptimal infant breastfeeding, stunting, wasting and micronutrient deficiencies account for 45% of child deaths annually.
Maternal undernutrition, defined as a body mass index less than 18.5 kg/m2, affects more than 10% of women in Africa and Asia. Undernutrition is associated with an increased risk of maternal mortality and morbidity and, for the child, an increased risk of fetal growth restriction or infants who are small-for-gestational age (SGA). In 2010, it was estimated that 27% of all births in LMICs were born SGA, increasing risks for neurodevelopmental delays and an important contributor to childhood stunting (Black et al., 2013). Micronutrient deficiencies, or ‘hidden hunger’, are still extremely widespread. In developing countries every second pregnant woman and about 40% of preschool children are estimated to be anaemic, in many instances due to iron deficiency (World Health Organization, 2015).
For young children, the most significant nutrition-related risk factor associated with poor developmental outcomes is stunting (low height-for-age, defined as more than two standard deviations below the median for the child’s sex and age) (Grantham-McGregor et al., 2007). The global prevalence of stunting in the first five years of life in 2011 was 25.7%, with a vast difference between high-income countries (7.2%) and LMICs (28%) (Black et al., 2013). Stunted children are more likely to have impaired cognitive and executive functioning skills, poorer academic attainment and retention in school, and subsequent lower economic productivity (Grantham-McGregor et al., 2007; Walker et al., 2007, 2011a). More recent evidence suggests that stunting has an impact on two generations by also affecting the cognitive development of the offspring of persons with early stunting (Walker et al., 2015).
In addition to exposure to early nutritional deficiencies and poor growth, suboptimal breastfeeding and feeding practices for infants and young children can further compromise children’s nutritional well-being (Yousafzai et al., 2013). A study of feeding practices in 28 countries in 2012 showed that only 25% of infants under 5 months of age were exclusively breastfed, and only half of those aged 6 to 8 months had received complementary foods the previous day. Median duration of breastfeeding was low even among countries with a high Human Development Index (Arabi et al., 2012).
Figure 1 describes possible pathways showing how nutritional status might affect children’s development. One pathway is direct, suggesting some nutrients support the structure and functioning of regions of the brain responsible for learning. Alternatively, a child who is physically less healthy may explore their environment less or the caregiver may respond differently to a child who is physically unhealthy or small, reducing opportunities for the child’s social interaction and exploration of his or her environment (Prado and Dewey, 2014).
Along with nutrition, inadequate stimulation is another significant risk factor associated with poor early development. Stimulation is a process whereby an external object or event elicits a physiological or psychological response from a child. The promotion of a child’s development does not depend on the provision of stimulation materials alone (such as the provision of toys), but also on the interaction of the child with the caregiver to promote learning opportunities and social interactions.
The ‘Early Child Development’ module of the UNICEF Multiple Indicator Cluster Surveys (MICS) is the only population household survey that collects information about a young child’s exposure to learning opportunities and social interactions. In Round 3 of the UNICEF MICS (2005–2006), the availability of three or more books in a household indicated inequalities between countries; for example, 97% of households in Ukraine reported owning three or more books for young children, while only 3% of households in the Lao People’s Democratic Republic owned a variety of children’s books. Inequalities were also seen within countries; for example, in the wealthiest 20% of households in the Lao People’s Democratic Republic, ownership of three or more children’s books was more than 10%. With respect to adult involvement in play and learning with young children, inequalities were observed between countries; for example, over a period of three days, 85% of mothers studied in Trinidad and Tobago were involved in four or more play activities with their young children compared with only 5% of mothers in the Lao People’s Democratic Republic, and again inequalities were also observed within countries between the richest and poorest populations (UNICEF, 2012).
Promoting adequate nutrition and opportunities for learning and social interactions is essential to support the healthy development of young children. There is a growing movement to promote partnerships between nutrition and early childhood development programmes in order to mitigate common risks for children’s growth and development outcomes, promote common caregiving capacities to support children’s growth and development, and more effectively utilise common programme resources. Interventions may be child development specific – directly reaching families and children (for example, parenting education and support or nutrition supplementation) – or they may be child development sensitive, which either mitigate threats or promote opportunities that benefit families and children indirectly (for example, social welfare programmes that enable families to invest more resources for their children). The partnerships between nutrition and early childhood development programmes might be integrated through a common delivery platform or they might be policies that ensure a comprehensive range of interventions reach the child and family.
Integrating nutrition into wider interventions
There are multiple reasons to integrate nutrition and early childhood development interventions. Synergies between the interventions can be organised at the level of the child, the family and the programme.
Synergies at the level of the child
First, the promotion of children’s growth and development shares a common window of opportunity in the first 2–3 years of life. Interventions to promote healthy growth and nutritional adequacy include appropriate feeding practices (such as breastfeeding promotion) and supplementation (such as distribution of micronutrients) and are focused on the first 1000 days of life. This window of opportunity overlaps a period of rapid and sensitive brain development where protective interventions such as nutrition and the promotion of opportunities for learning and social interactions can effectively moderate the quality of early brain development (Black and Dewey, 2014).
Second, children’s healthy growth and development require both nutritional adequacy and opportunities for learning and social interactions. The promotion of growth and nutritional well-being requires interventions to address the immediate and underlying causes of poor nutrition. Additionally, development gains require maternal and child nutritional deficiencies to be remedied. Therefore, an approach integrating nutrition with early childhood development benefits both growth and development outcomes, and there is also the potential for additive or synergistic (that is, the impact of a specific intervention is enhanced by the presence of a second intervention) benefits to maternal and child outcomes (Grantham-McGregor et al., 2014).
Landmark research in Jamaica on stunted children who received either nutritional supplementation, stimulation (play), both interventions, or standard care found that each intervention had independent benefits to child development and nutritional supplementation also benefited child growth (Grantham-McGregor et al., 1991). The Jamaican cohort was followed to adulthood, and by 22 years of age, the stimulation intervention also benefited educational attainment and behaviour; however, no long-term benefits were observed as a result of the nutritional supplementation (Walker et al., 2011b). Research on integrated nutrition and stimulation interventions generally shows that the integrated approach can benefit multiple child outcomes, and that the addition of a stimulation intervention to nutrition services does not result in negative effects on the original service. Additive or synergistic benefits are less commonly observed; however, more research is needed to address this question (Grantham-McGregor et al., 2014).
Synergies at the level of the family
The provision of adequate nutrition and opportunities for learning and social interactions for the child is dependent upon the knowledge, skills and resources of the caregivers (Figure 2). Enhancing parenting capacities can potentially promote healthy child growth and development.
The enhancement of parenting capacity builds fundamental caregiving skills and provides support for the mental well-being of mothers and families. Sensitivity (the ability of the caregiver to observe and understand their child’s cues) and responsiveness (the ability of the caregiver to contingently and appropriately respond to their child’s cues) are interlinked fundamental parenting skills that support secure infant–caregiver attachment, relationships and care (Richter, 2004). Responsive caregiving behaviours are associated with benefits to children’s cognitive, language and social-emotional development (Eshel et al., 2006); early literacy and pre-academic skills (Hirsch-Pasek and Burchinal, 2006); decreased hospitalisations and ambulatory care visits and increased well-child visits (Holland et al., 2012). Responsive feeding behaviours have been found to support self-feeding skills and maternal verbal responsiveness (Aboud et al., 2009).
Parenting skills can be compromised by a lack of emotional availability on the part of mothers, which might impede maternal care for nutrition and development. Maternal depression is associated with low quality of stimulation in the home environment (Black et al., 2007) and poor child growth (Patel et al., 2004). Surkan and colleagues reported that, in selected studies in developing countries, if the infant population were not exposed to maternal depressive symptoms, 23–29% fewer children would be underweight or stunted (Surkan et al., 2011). In Pakistan, interventions to reduce maternal distress reported a 60% reduced risk of cessation of exclusive breastfeeding in the first six months of an infant’s life (Sikander et al., 2015). In other words, interventions that support the mental health and well-being of the caregivers bring similar benefits holistically to their young children.
Synergies at the level of the programme
At the level of programmes there are advantages to integration, including access to child development and nutrition services through a common delivery platform, efficiencies in the cost of services, coordination of nutrition and child development messages and colocation of services that benefit families. However, integrated services require integrated planning, supervision and monitoring that can be challenging to service providers (DiGirolamo et al., 2014). A summary of the advantages of integrated programming for nutrition and early child development interventions is shown in Box 1.
Effectiveness of integrated interventions
Recent meta-analyses reported that stimulation interventions had a medium-sized impact on child cognitive development outcomes, while nutrition interventions had only a small impact (Aboud and Yousafzai, 2015). Therefore, while adequate nutrition is critical for child growth and contributes to development, promoting nutrition is not on its own sufficient to promote child development. A number of studies have investigated the outcomes of integrated nutrition and early childhood development interventions. Overall, the evidence suggests that this is likely to improve multiple outcomes for young children: the early childhood development components typically benefit children’s development, while the nutrition component may benefit both development and nutrition-related outcomes (Grantham-McGregor et al., 2014).
Integrated approaches typically use existing health service infrastructure; however, a range of delivery opportunities might be identified in different contexts for planning integrated strategies. Table 1 illustrates examples of programmes from Uganda, Colombia and Pakistan that have used different delivery platforms as opportunities to integrate nutrition and early childhood services. Child development and care benefits were observed in all three programmes.
Successful implementation requires attention to programme quality. Yousafzai and Aboud (2014) reviewed 31 integrated nutrition and child development interventions to identify features of their implementation that were likely to be associated with more or less effective integrated programmes. Key findings for best practice are summarised in Table 2. The successful implementation of integrated interventions is dependent upon context. Programme coordination with interventions that are child development sensitive might identify strategies that mitigate threats or promote opportunities to benefit caregiving capacity and children’s outcomes (Table 3).
Summary and recommendations
In 1999, the World Health Organization published A Critical Link: Interventions for physical growth and psychological development, which reviewed the approaches for integrating nutrition, stimulation and care (Pelto et al., 1999). In the last 15 years, new studies have contributed to strengthening the evidence base for the efficacy of integrated interventions. As we approach the post-2015 sustainable development era, the partnership between nutrition and early childhood services is one that promotes a continuum of care from child survival to strengthening thriving. However, questions remain about how to optimise packages of care, strengthen the necessary coordination with a range of family and child interventions, and implement them effectively in programme settings at scale. Box 2 summarises recommendations for practice, policy and research.
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