Window of Opportunity for Enriched Childhood
by Joseph M. Hunt
THEMES
- Health and Nutrition for mother and infant should be priorities for all developing countries but rarely are.
- Empowered women raise tall, bright, healthy children. Women’s rights and children’s rights are interwoven and non- negotiable.
- Investing in early childhood is the investment bargain of the decade.
- Community- based programs that integrate food, health and psychosocial care are the most successful.
- Lifelong learning and earning are the outcome.
- Human and Economic Development are two sides of the same coin.
- Child Development IS Sustainable Development.
Malnourished children are the scars of global poverty global poverty
- 150 million underweight
- 177 million stunted
- Nearly 3 billion people suffer from iodine, iron and vitamin A deficiencies
* Most are poor children and their mothers
- 11 million children under five die each year
- Poor Health and Nutrition is the Main Cause
- Malnourished Survivors bear the brunt
- poor cognitive and learning skills
- low achievement in school
- low wages
- low investment in Quality of their Children
- disability (mental and physical)
- shortened life
- life- long susceptibility to illness (double risk of hypertension, heart disease and diabetes
Asia is the “Big Show” for Improving Children’s Prospects
- Three- quarters of the underweight, stunted and micronutrient deficient people live in Asia, the majority children
- 72 million children born yearly
- 26 million (36%) underweight
- 6 million die before age 5
- malnutrition underlies 3 million deaths
- Half of young women and preschoolers are anemic
- 65,000 maternal deaths each year
- school dropouts
- 30 million kids (ages 6 -11) not enrolled in school
- 150 million (ages 5- 14) working, half full- time
- 1 billion people (400m children) need iodized salt to avoid iodine deficiency, which robs children of 13 IQ points
Turning the Spiral of Malnutrition dull Minds and Poverty…..
To a Virtuous Cycle of Learning and Earning! The Key is Enriching Early Childhood
International Development Goals by 2015
- Eliminating most of infant, child, and maternal deaths.
- Reduction of extreme poverty by half.
- Universal primary school enrolment
Improved maternal and child nutrition is essential to accomplish these goals. Why?
- One fifth of maternal deaths (65,000 in low- income Asia each year) are caused by iron deficiency anemia
- 54% of under- five child deaths in Asia (2.8 million each year) are caused by moderate and severe underweight condition.
- Low birth weight infants (from short, undernourished mothers) are ten times more likely to die in their first year than normal birth weights.
- Stunted children enter school later and are more likely to drop out
- Malnutrition reinforces poverty, low mental competence, achievement, and earnings, and depresses economic growth by at least 5% of GDP.
The “Education for All” Evaluation (1990 — 2000)
Universal Primary School Enrollment could not be reached because of preschoolers’ poor “readiness for learning.”
Primary dropout and retention rates have not improved enough.
Poor nutrition dulls learning capacity.
The Life-Cycle Perspective
- There is new evidence on importance of:
- Nutrition of girls
Fetal development Nutrition of next generation of girls
- Fetal development Adult chronic disease (a linking of the two burdens)
- Fetal development
- This gives us an expanded view of:
- Productivity impacts of improved nutrition
- Opportunities for action
Main Child Nutrition Problems
- Underweight
- Stunting
- Micronutrients
Underlying Trends Leading to Increased Non-Communicable Diseases
- Fetal and infant insults interacting with subsequent shifts toward positive energy balance
- Shifts in the structure of diet
- Shifts in physical activity
- Obesity trends
- Morbidity and mortality shifts
Direct Nutrition Interventions for Undernutrition
- Low birth weight:
- Improve pre- pregnancy weight (adolescents)
- Increase pregnancy weight gain
- Young child growth:
- Exclusive breastfeeding to 6 months
- Complementary feeding from 6 months
- Micronutrient supplementation
- Fortification
- Iron deficiency
- Supplementation, fortification, diet modification
- Iodine deficiency disorders
- Salt iodization, iodized oil
- Vitamin A deficiency
- Breastfeeding, supplementation, diet mod., fortification
| Studies of term SGA babies < 24 months | ||
| Study | Age (mos.) | Significant deficits |
| Low | 6 | – |
| Villar | 6 | – |
| Grantham- McGregor | 6 | PDI, MDI |
| Rubin | 8 | – |
| Parmelee | 10 | – |
| Nelson | 12 | PDI |
| Low * | 12 | PDI, MDI |
| Grantham- McGregor | 12 | PDI, MDI |
| Villar * | 15 | – |
| Villar * | 24 | mental scale* |
| Tenovuo | 24 | Denver* |
| Studies of SGA | ||
| Study | Age (yrs.) | Significant deficits |
| Gorman | 36 | Language |
| Walther | 36 | Language |
| Pryor | 48 | IQ |
| Babson | 48 | – |
| Fancourt | 48 | DQ < 26 wks. |
| Fitzhardinge | 48 | Sch. Achiev. |
| Harvey | 60 | IQ < 26 wks. |
| Gorman | 48 and 60 | – |
Behaviour of SGA children
<2 years (2 studies) less active, vocal, happy, responsive
>2 years (5 studies) less happy, attentive more fidgety, anxious
| Significant Associations with Height-for-Age | ||
| Study | Country | Outcome |
| Agarwal | India | + ability, arithmetic |
| Bogin | Guatemala | + language |
| Clarke | Jamaica | + achievement |
| Cravioto | Mexico | + neurosensory integration |
| Florencio | Philippines | + achievement, concentration |
| Freeman | Guatemala | + language |
| Huda | Bangladesh | + math score, learning |
| Jamison | China | + achievement |
| Johnston | Guatemala | + IQ |
| Moock & Leslie | Nepal | + enrollment/ achievement |
| Sigman | Kenya | + cognitive score (girls) |
| Wilson | Guatemala | + achievement/ verbal ability |
Behaviors which were significantly different in stunted group
Child
- Variety of exploration
- Enthusiasm of exploration
- Activity
- Happy
- Fussing
- Crying
- Apathy
Caretaker
- Positve vocalisation
(Meeks-Gardner et al., 1998)
| Relationship between change in height and mental age over 2 years | ||
| B | S.E. | |
| Mental age |
0.37 | 0.13** |
| Locomotor |
0.84 | 0.29** |
| Hearing and speech |
0.66 | 0.26** |
| **p< 0.01 Controlling for age, sex, SES, intervention, birthweight Source: Powell et al., 1995 |
||
Iron deficienc anaemia (110g/ l) in children under five
- Developing countries 46 – 51 %
- Developed countries 7 – 12 %
(DeMeyer et al, 1985)
| Relations between infections & development in Kenyan girls (n= 57) | |||
| Bayley | 5-year | ||
| Mental | Motor | Cognitive Test | |
| Mild | -0.14 | -0.19 | -0.38** |
| Severe | -0.27* | -0.12 | -0.19 |
Women’s Education and Empowerment
Conclusions of a Seven- Country Asian Review of Women’s Impact on Child Nutrition (ADB- UNICEF)
- Equality in women’s status relative to men has a positive impact on children’s survival, growth, and development.
- The low status of women, particularly in South Asia, inhibits the rapid improvement in children’s profile.
- Women’s education, through formal and non- formal means is a major predictor for decline in total fertility rate, and infant and child mortality, and underweight incidence of under- fives.
- Changing the legal environment to protect women’s rights, including the right both to work and expect child care support, is essential.
- Care for women is rights- based and an instrument for better child care.
| Priorities for the region in underlying determinants: 1970- 95 | ||
| Underlying determinant | Strength of impact on child underweight, 1970- 95 | Percent below desirable level In 1995 |
| South Asia | ||
| Safe water access | 4 | 4 |
| Female education | 2 | 1 (largest gap) |
| Women’s status | 3 | 2 |
| Food availability per cap | 1 (strongest impact) | 3 |
| East Asia | ||
| Safe water access | 4 | 3 |
| Female education | 2 | 1 (largest gap) |
| Women’s status | 3 | 2 |
| Food availability per cap | 1 (strongest impact) | 4 |
| Source: Smith and Haddad 2000 | ||
Core Package for Mothers and Young Children
- The menu of options is well established, but must be adopted based on local situation analysis.
- For young children, growth monitoring and promotion, promotion of exclusive breastfeeding for six months and appropriate complementary feeding practices (at about 6 months), disease management, appropriate nutritional management during and after illness, micronutrient supplementation, deworming, and possibly targeted food supplementation based on GMP.
- For women, ante- natal and post- natal care for women including tetanus toxoid immunization, micronutrient supplementation, food supplementation during pregnancy, malaria chemoprophylaxis in endemic areas and reproductive health education.
- Based on clinical trials ongoing, it is expected that integrated management of childhood illness (a WHO initiative) and multi- micronutrient supplement programs for pregnant and nursing mothers will be added to the core package around the world in the near future.
What determines the success of large – scale community – based nutrition programs?
| Community-government partnership | |
| Government delivery | Convergent service |
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| Facilitator | Supervision/support |
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| Program planning, design, implementation, M&E | |
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| Mobilizer | Social mobilization |
| Community | Setting goals, indicators, priorities |
THAILAND’S STUNNING SUCCESS STORY
1982: Half of preschoolers malnourished
1991: Only one in five still malnourished, moderate and severe malnutrition virtually eliminated. Fastest rate of reduction in the world (3% per year)
Strategy
- Enfold PEM reduction in national poverty alleviation program, so local governments responsible for targets
- Growth monitoring quarterly, to target at risk families with nutrition education and communication to encourage breast-feeding, timely introduction of complementary foods, correct hygiene and dietary practices.
- Strengthen food security in very poor areas, selective school lunch program
- National iodized salt program
Lessons
- Integrate food and nutrition with poverty programs
- Link facilitators to mobilizers for family support of lagging children
- Sustained support of social infrastructure through “thick and thin” pays off
Contextual success factors
- Political commitment
- Gender and social equity
- Organizational capacity
- Leadership
- Convergence of programs
Program success factors
- Awareness and understanding
- Community ownership
- Outcome and process orientation
- Community-government partnerships
- Appropriate program design
- Good management, incl. info systems
INCAP LONGITUDINAL STUDY (Guatemala)
Intervention Study (1969-1997):
experimental and control villages
target groups: pregnant women mothers of young children (<2 yrs.), children up to 7 years participants received a nutritious drink (“ATOLE”), controls a sugar drink
Follow-up Study (1987-88)
2000 subjects (82% traced)
measurements: body size and composition, work capacity, and intellectual performance
Key results: “Atole” adults were taller and had greater fatfree mass; half of “Atole” women were very short and two-thirds of controls were at obstetric risk (<149 cm height)
Work capacity was much higher for “Atole” subjects. Males earned higher wages
“Atole” subjects were superior in adolescence by five indicators of intellectual achievement, including a literacy test. In both groups, degree of stunting predicted intellectual performance
Early Childhood Programs
- Highest Benefits
- Least Cost
- Life-long stream for persons, families, nations
- Fulfills mandates under Convention for Rights of the Child
- Supports Global Peace
DESIGN PRINCIPLES
- Integrated Service Delivery
- Life Cycle Approach
- Pregnancy & newborn care
- Nutrition and psychosocial care for under twos
- Psychomotor/brain development under threes
- 4-6: PSD/cognitive development maintain H/N)
- 7-8: enriched child readiness for School/School Readiness for kids
- National Support Systems for local capacity
- Local Support for Community/Family Environment
- R&D
ADB-UNICEF Asia Study (1999) Linking Nutrition and Psychosocial Care
Patrice Engle, UNICEF India
- A. Findings
- long term benefits on later child development and functioning
- care directed to under 3s improves survival, growth and development of children
- assessment of home environment is as crucial as individual assessment
- developing countries have more “collective” cultures, so interventions more directly with caregivers are more effective
- Sensitivity and responsiveness of the caregiver to the child’s emerging abilities is a key.
- Care for pregnant women improves their ability to care for children.
- B. Programs
- Home visits and center-based services are both essential for comprehensive care
- Assessment instruments and outcome indicators for care should design, monitor and evaluate home visits
- Assessments particularly of organic problems and developmental delays, should be linked to a referral system
- Interventions should target the most needy areas and the most needy children, especially LBWs.
COUNTRY EXAMPLE: PHILIPPINES’ EARLY CHILDHOOD DEVELOPMENT PROGRAM (1998 – 2007)
- Ten year investment program endorsed by the Cabinet of the Philippines.
- Integrated program addressing the health and nutrition needs of mothers and underthrees, early education for 4-5 year olds, and an ECD-enriched Curriculum for Grades I-II.
First Phase:
Targets 5 million pre-school children in 170 municipalities and chartered cities en Visayas and Mindanao (11% of local government units) – half the children at developmental risk, others to be helped in second phase.
Supporting or “indirect” actions
- Food Security: Increase the poverty and malnutrition focus of agriculture and agricultural research
- Care: Improve the status of women and girls
- Health and Sanitation Environment: Improve the delivery of effective sanitation and water infrastructure to the poor
ECD Benefits
- nutrition has an impact on health through immuno-competence and stronger resistance to life-threatening infection;
- health has an impact on nutrition in that reduced illness leads to height and weight gain;
- nutrition and health improve psychosocial development and learning through better psychomotor skills and socialized vitality; and
- nourished children who attend preschool are better socialized as preschoolers, less likely to drop-out of primary school, adjust better to the social and academic environment of school, and perform better, especially in the early grades.
Poverty Reduction Through ECD
The program is a model for poverty targeting. Child development indicators on undernutrition, mortality, and primary school dropouts were used to rank about 1,500 local governments according to the number of children at developmental risk. Results: 170 local governments are participating over six years in an ECD project confirmed by Government of Philippines, Asian Development Bank and World Bank.
Information Systems for Decentralized Decision-Making
The ECD project has designed an integral management information system that effectively uses microcomputer-based information technologies at the sub-national level.
The MIS is used to:
Identify populations to be targeted for assistance
Assist in decision-making about the nature of the services required.
Support advocacy to create demand and local ownership for the ECD programs, and
Provide the basis for assessing impact and sustainability of the program.
Governance and Fiscal Accountability
The ECD project contributes to governance improvement through tailored investment plans for each local government. These plans are negotiated with national government based on cost-sharing rules reflecting the municipality’s ability to pay.
CHILD DEVELOPMENT ASSESSMENT INSTRUMENTS
A. PROJECT INDICATORS
- Anthropometry
- Impact Weight-for-age U5CMR,LBW, PDI, MDI
- Weight-for-height LBW, PDI
- (mom, infant)
- Height-for-age mental development
- IDA poor attention, memory, MMR
- IDD IQ loss
- Recent Morbidity History
- Assessment of Pyschomotor Skills and
- Disabilities
B. ASSESSMENT PROCESS
- Required:
- Social Assessment
- Baseline and Inter-linked Surveys
- Options:
- Home Screening Instrument
- Limit Age Survey
- Measuring Development Quotient
- ECD Checklist
- Measuring Longitudinal Impacts
LIMIT AGES FOR VARIOUS CHILDHOOD ABILITIES
| Age (months) | Ability by Stated Age |
| 1 | Some indication of attention |
| 2 | Attention to objects |
| 3 | Head held erect |
| 4 | Hands not fisted Shows ordinary interest in people and playthings |
| 5 | Reaches for objects |
| 7 | ATBR not present or producible |
| 9 | Visual fixation and following established |
| 10 | Holds objects in hand Gives attention to gestures Sits independently on firm surfaces Uses tuneful babble to self and others Bears most weight on legs Chews lumpy food |
| 12 | Attends to words |
| 15 | Releases held objects |
| 18 | Walks alone No casting, mouthing, drooling |
| 21 | Kicks when standing Single words with meaning |
| 3 years | Puts 2-3 words together in phrase Can stand on one leg Talks in sentences |
| 4 years | Uses fully intelligible speech |
PARENTAL LEARNING / PARENTAL EFFECTIVENESS
- Strongest predictor of child’s educational success is father’s occupation and income.
- But the greatest predictor of child’s nutrition status and readiness for schooling is the mother’s education level and control over economic resources. economic resources.
- Why?
Mortality decline precedes fertility decline.
< Iron law of demography > - Women’s care and empowerment is essential to eliminate low birth weight.
- Reduce infant and child mortality
- Improve cognitive potential of all children
- Childprepared for learning
- Girl’s education beyond primary school predicts lower fertility rate.
- 40 countries: when half of girls’ age cohort enrols in junior secondary, lagged effect is halving the total fertility rate.
- Why does this help child readiness for schooling? Educated women work and earn before marriage, marry later, and share decision making with their husbands on when to have children, how many, and how to space them. They continue working during their reproductive years, and influence use of household earnings to raise the quality of each child. Maternal bonding and caring practices improve psycho-social stimulation, early language acquisition, self-confidence, socialization at play, and the child’s positive affect at 4 predicts good reading skills at 8.
The Big Message
Educated parents make correct decisions if they have resources, good information, and societal support for nurturing their children. They don’t need extra children for “Old Age Insurance.” Mothers and fathers have critical but complementary roles in fostering child development and academic achievement.
Annual Earnings and Savings from Improvement in Nutrition, Estimates for 1999
| Pesos (millions) | Dollars (millions) | |
| Current earning from increased agricultural productivity because of a 50 percent reduction in anemia | 1,340 | 48 |
| Future wages gained because of a 50 percent reduction in iodine deficiency, mortality, and stunting | 8,400-19,600 | 300-700 |
| Savings in government health expenditures because of a 50 percent reduction of malnutrition-realted diarrhea, blindness, and acute respiratory infections | 168-672 | 6-16 |
Other Benefits (6 yrs)
144,000 lives saved
Higher IQs 400,000 infants (+13 pts .)
Source: Heaver, R. and Hunt, J. 1995. Improving Early Childhood Development: An Integrated Program for
the Philippines, Washington, DC, The World Bank.
Disability Adjusted Life Year (DALY)
A composite index of health linked to a productive life usually referred to as “A Year of Healthy Life Saved.” DALY is a weighted index that takes into account loss of life, morbidity, and disability and their collective impact on productivity.
Nutrition & Health Investment which are Cost-Effective
DALY SAVED < $25:
- EPI plus
- School Health (esp.iron/deworming)
- Health, Nutrition and Family Planning Information
- Breastfeeding promotion
- Salt iodization
- Staple fortification: vitamin A and iron
- Semi-annual mass dose of vitamin A
- Iodine injections for pregnant women
- Daily (and probably weekly) oral iron for pregnant women
DALY Saved ($25-$75):
- Improved weaning practices for children
- Food supplements for children
- Food supplements for pregnant women
Nutrition and Quality of Children’s Lives: Priorities for Developing World
- Approach adequate nutrition as a human right for all citizens and an issue of governance since the foundation of a productive life is at stake
- Encourage local governments and communities to develop partnership and solve nutrition problems towards the collective good.
- Support the social economic, and political rights of women through legal and regulatory reform, so that they are empowered to care for their children.
- Focus programs on poor mothers and children under three to avoid preventable death and disability, and minimize risks later in life.
- Develop programs for preschoolers that integrate child health, nutrition, psychosocial and cognitive development. The payoffs are healthier and better adjusted children, who grow into productive adults.
- Shift the role of government gradually from service provider to enabler and catalyst.
- Rally the public and private sectors to support the quality of affordable staples and complementary foods to raise the prospects of the poorest children. Food industry and agricultural research can have a big impact.
- Helping mother and child today avoids life-long risks.
- Regional consensus – building pushes nations to act for children.
Regional Nutrition Action is Needed
Correcting micronutritient deficiencies can
- improve population-based IQ by 15 points
- reduce maternal deaths by 20 -25%
- decrease infant and child mortality by 40%
- increase work capacity by almost half
- reduce health care and education costs by lowering illness and dropout rates
- add at least 5 percent to long term economic growth
ADB’s Current Activities to Eliminate Child Malnutrition and Improve Educational Achievement
- Philippines: Early Childhood Development Project (1997 – 2003)
- Regional Investment Plan for Fortification of Essential Staples
- Rice Plant-Breeding to Reduce Anemia and Zinc Deficiency
- Regional Salt and Flour Fortification in Central Asia and Caucasus