Knowledge for Development Policy Brief: Malawi May 2016 Education Global Practice Early Childhood Development: Health, Nutrition, and Population Global Practice A Review of the Global Evidence Sophie Naudeau and Rifat Hasan This policy brief examines international typically suboptimal, in part because they are evidence on the health, nutrition, early not exposed to sufficient opportunities for learning, and overall development of young early learning and development. For example, children with a focus on children born to studies in five Latin American countries (Chile, adolescent mothers and reviews Colombia, Ecuador, Nicaragua, and Peru) ­ evidence-based approaches to improving recorded large cognitive differences between early childhood development. children in the poorest and richest segments of society. The bulk of these differences was Why Early Childhood Development apparent by age 3, often worsened by age 6, Matters and remained largely unchanged after that Early childhood development (ECD) refers (Schady et al. 2014). Similar gaps were to the physical, cognitive, socioemotional, documented in other parts of the world, and linguistic development of young including in Cambodia, Ethiopia, India, children until they enter primary school. Madagascar, Mozambique, and Vietnam The field of ECD is framed by the United (Engle et al. 2011; Fernald et al. 2011; Naudeau Nations Convention on the Rights of the Child, et al. 2011b), setting children from disadvan- and the Sustainable Development Goals now taged backgrounds on a suboptimal trajectory include a specific ECD target (among several for the rest of their lives (figure 1). Children other relevant targets for young children) as born to teenage mothers may be particularly follows: “By 2030, ensure that all girls and at risk because they are more likely to come boys have access to quality early childhood from poor or uneducated households. For development, care, and preprimary education example, adolescent pregnancy is associ- so that they are ready for primary education.” ated with a 50 ­ percent increased risk of Developmental gaps in the early years of stillbirths and neonatal deaths and increased a child’s life lead to costly consequences risk of preterm birth, low birthweight, and for individuals, families, and societies. asphyxia, putting children at elevated risk Malnutrition in early childhood significantly early on (Bhutta et al. 2013). impairs proper development of the immune system and cognitive functions, making it What Works difficult for children to stay healthy and to There is strong evidence that ECD inter- learn in school as they become older. As a ventions yield significant benefits in the result, children who are stunted by 24 months short and longer terms. Many brain func- typically earn 10–20 percent lower wages tions are particularly sensitive to change throughout their productive lives (Grantham- early in life and become less malleable over McGregor et al. 2007). Beyond malnutrition, time. Much of a child’s brain architecture is the overall development of young children “wired” in the first five years of life (Shonkoff from the most vulnerable households is and Phillips 2000). Various ECD interventions 1 Figure 1. Differential Trajectories of Brain and Behavioral Development as a Function of Exposure to Risk and Protective Factors Optimum B h vior l comp t nc tr j ctori s Prot ctiv > risk f ctors R duction in risk f ctors, incr s in prot ctiv f ctors, or int rv ntion durin s nsitiv p riod function Br in B low Risk f ctors > prot ctiv f ctors pot nti l Pr n t l Birth E rl childhood Adol sc nc Adulthood A Optimum R cov r B low pot nti l Source: Walker et al. 2011 have been shown to have significant and Interventions to promote infant and long-lasting benefits by enhancing school child health and to reduce malnutrition are readiness and related educational outcomes, most effective in the 1,000-day window improving physical and mental health and from pregnancy to a child’s second birth- reducing reliance on the health care system, day. Worldwide, maternal undernutrition and reducing engagement in high-risk contributes to 800,000 neonatal deaths ­ behavior (for a review, see Naudeau et al. annually through small-for-gestational-age 2011a). As a result, ECD interventions have births, while stunting, wasting, and micronu- not only a high cost-benefit ratio but also a trient deficiencies contribute to nearly higher rate of return for each dollar invested million child deaths annually (Bhutta et al. 3.1 ­ than interventions directed at older children 2013). Interventions aimed at improving and adults. Evidence suggests a potential maternal health and nutrition are critical for a return of 7–16 percent annually from strong early start. Evidence from a systematic high-quality ECD programs targeting vulnera- review suggests that interventions addressing ble groups in the United States (Heckman et reproductive health, family planning and al. 2009). Recent estimates also show that counseling, and promotion of exclusive expanding preschool enrollment to 50 breastfeeding and complementary feeding percent of all children in low- and middle-in- interventions, especially for adolescent girls, ­ come countries could result in lifetime gains can reduce the risk of small-for-­ gestational- in earnings ranging from US$14 billion to age birth, optimize age at first birth, reduce US$34 billion (Engle et al. 2011). Many unwanted pregnancies, and help to achieve countries invest public resources in ECD as a healthy birth spacing of 18–24 months way to enhance both efficiency and equity by (Bhutta et al. 2013). Maternal nutrition leveling the playing field for the most vulner- interventions can reduce the risk of low-­ able children and giving them an opportunity birthweight infants births by providing to lead happy, fulfilling, and productive lives. balanced energy protein, calcium, multiple Different types of ECD interventions micronutrient supplementation (including make sense and are complementary at iron-folate), and strategies for preventing different times of a child’s development. malaria during pregnancy. Vitamin A and zinc Development in early childhood is a multidi- supplementation in children 6–59 months of mensional and sequential process, with age is another core nutrition intervention. progress in one domain catalyzing develop- Treatment strategies should be employed to ment in other domains, and some specific address both severe and moderate malnutri- interventions are particularly relevant during tion. If these nutrition interventions are scaled “windows of opportunity.” Figure 2 summarizes up to 90 percent coverage, stunting could be the types of interventions that are most reduced 20 percent, severe wasting 61 percent, relevant at different stages in early childhood. and deaths of children under 5 years nearly 2 Figure 2. Key Interventions for Young Children and Their Families 12 24 36 48 60 Pr n nc Birth months months months months months Couns lin on d qu t di t durin Exclusiv Compl m nt r f din Ad qu t , nutritious, nd s f di t pr n nc br st- f din Th r p utic inc suppl m nt tion for di rrh Nutrition Iron-folic cid for pr n nt moth rs Pr v ntion nd tr tm nt for cut m lnutrition (mod r t nd s v r ) Micronutri nts: suppl m nt tion nd fortific tion Ant n t l visits Immuni tions Att nd d d liv r D wormin Pl nnin for f mil si nd sp cin Acc ss to h lthc r H lth Acc ss to s f w t r Ad qu t s nit tion H i n nd H ndw shin Pr v ntion nd tr tm nt of p r nt l d pr ssion M t rn l duc tion Educ tion Educ tion bout rl stimul tion, rowth, nd d v lopm nt E rl childhood nd pr prim r pro r ms Continuit to qu lit prim r Birth duc tion R istr tion Soci l P r nt l l v nd d qu t childc r prot ction Child prot ction s rvic s Soci l ssist nc tr nsf r pro r ms Source: Denboba et al. 2014 20 percent, saving 1 million lives (Bhutta et al. Two decades later, the children who had 2013). Using community-based and other received early stimulation (with or without innovative delivery platforms for many of nutrition) had earnings 25 percent higher than these interventions may better enable those who had received nutrition only or no scale-up. Since many of these interventions intervention at all (Gertler et al. 2014). are delivered through the health system, close Promoting early stimulation in a way links and complementarity with efforts to that generates positive impacts can take strengthen health systems are critical (Horton multiple forms. There is no one-size-fits-all et al. 2010). approach for encouraging parents and other Programs that enhance both early caregivers or family members to adjust their stimulation and nutrition are more likely behavior and engage in increased and high- to generate long-lasting impacts than er-quality interactions with young children. nutrition alone. A systematic review and The specific details that are most relevant in meta-analysis of 21 interventions that a given context will depend largely on the improved nutrition revealed that stimulation services and financial and human resources had a medium-size effect of 0.42 and 0.47 on available. The types of approaches that have cognitive and language development, respec- been effective across regions and countries tively, whereas nutrition by itself had a smaller include providing parenting information in the effect of 0.09 (Aboud and Yousafzai 2015). context of maternal and child health or Several options exist for combining early growth-monitoring visits (as in Tajikistan or stimulation and nutrition interventions in the Kyrgyz Republic), through home visits for specific contexts (Alderman et al. 2014). In the most at-risk families (as in Jamaica, St. Jamaica, a ground-breaking, long-run random- Lucia, and Brazil), through a combined ized study initiated in 1986 demonstrated that approach (as in Bangladesh and Honduras), or stunted children 9–24 months of age who even through group meetings at the commu- received both a nutritional supplement and nity level (as in Mexico). In other contexts, early stimulation benefited much more than various technologies (cell phones, television, those who received either intervention alone. radios) have been used to reach large 3 numbers of children and parents with Providing cash transfers to families can educational messages to promote early enhance the ECD outcomes of the poorest stimulation and learning at very low cost, children. For some families, simply providing including Bangladesh, Turkey, and Zanzibar information (on the benefits of early stimula- (for a review, see Engle et al. 2011). Finally, tion and adequate nutrition) or increasing children are likely to benefit most when both access to quality preschools may not be fathers and mothers are engaged in early sufficient to change behavior and to generate stimulation activities (Barker 2015). lasting benefits for children if other con- Strong evidence also exists on the straints, such as cash or time, prevent them positive impacts of high-quality center-­ from using these services effectively. In such based programs for young children (day- contexts, targeted cash transfers can be care and preschools), including in low- and highly beneficial, especially when they are middle-­income countries. While the impact implemented in synergy with the provision of of quality center-based care has been docu- relevant ECD services. In particular, cash mented in high-income countries, recent transfers and related safety nets can help to evidence shows that quality daycare and remove financial barriers and to improve preschools can have significant positive access of families to child health services and effects on a child’s overall development and appropriate food and nutrition commodities, school readiness in a wider range of countries, especially for the poorest (Horton et al. 2010). including in Argentina, Bangladesh, Chile, For example, a cash transfer program in China, Colombia, Costa Rica, Kenya, Uganda, Bangladesh significantly reduced the inci- Uruguay, and Zanzibar, to name a few (Engle dence of wasting among children 10–22 et al. 2011), and additional evidence continues months old (Ferre et al. 2014), while one in to emerge, as in Indonesia and Mozambique, Burkina Faso boosted preventive health care among others. In many cases, the poorest visits more than 40 percent for children 5 benefit the most, highlighting the need to years of age and younger (Akresh, De Walque, ensure adequate targeting for publicly funded and Kazianga 2013). Cash transfer programs ECD interventions. However, ECD programs can also yield positive benefits for young need to be of sufficient quality in order to children beyond health and nutrition, espe- yield significant positive impacts, as several cially when parents also receive information studies have shown that poor-quality pro- about early stimulation. In Nicaragua, for grams do not yield benefits. example, a cash transfer achieved sustained Center-based care for young children improvements in children’s cognitive and can also generate positive impacts for socioemotional development (Macours, other family members, including caregivers Schady, and Vakis 2012). and siblings. A study in Argentina looked at the effect of large-scale increases in the Conclusions availability of free preschools nationwide and Early childhood is a critical period of human estimated an effect on increased maternal development. While the poorest children are employment of 7–14 percent (Berlinski and at greatest risk of lagging behind early in life, Galiani 2007). Another study of Argentine several types of ECD interventions have been families estimated a 13 percent difference in proven effective to improve their develop- workforce engagement in favor of mothers ment and life-long prospects. Programs to whose youngest child just made the age improve infant and child health are most cutoff for preschool eligibility versus those effective when they combine maternal health whose youngest child just missed the age and nutrition interventions, community-based cutoff (Berlinski, Galiani, and McEwan 2008). distribution of health supplies, integrated Similarly, a randomized study on the impact service delivery, and postpartum counseling of community-based preschools in a rural on infant feeding practices. Before and area of Mozambique found that the caregivers during pregnancy, programs that address of participating children were 26 percent women’s reproductive health and nutrition more likely to have worked in the previous are essential for healthy gestation and a month and that older siblings were 6 percent strong foundation. For children 0–2 years of more likely to be enrolled in school (Martinez, age, programs that combine early stimulation Naudeau, and Pereira 2012). These findings and nutrition are most likely to yield long- may be particularly relevant for teenage term effects. Center-based care can also mothers, who can find it challenging to pursue promote child development, while freeing up their education or to engage in productive caregivers’ time, but quality is paramount activities due to childcare constraints. to ensure positive outcomes. For children 4 3–6 years old, preschools can be a highly Child Development in a Very Low-Income Population: cost-effective way to enhance school readi- Evidence from Madagascar.” Developmental Science 14 (4): 832–47. ness and success later in life, as long as a Ferre, Celine and Iffath, Sharif. 2014. “Can Conditional sufficient level of quality can be ensured. 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The World Bank does not guarantee Behrman, Chloe O’Gara, Aisha Yousafzai, Meena Cabral Academy Press. the accuracy of the data included in this work. de Mello, Melissa Hidrobo, Nurper Ulkuer, Ilgi Ertem, Walker, S. P., T. D. Wachs, S. Grantham-McGregor, This work is subject to a CC BY 3.0 IGO license (https://creativecommons.org/licenses/by/3.0/ and Selim Iltus. 2011. “Strategies for Reducing N. N. Black, C. A. Nelson, S. L. Huffman, H. Baker- igo). The World Bank does not necessarily own each Inequalities and Improving Developmental Outcomes Hennningham, S. M. Chang, J. D. Hamadani, B. Lozoff, component of the content. It is your responsibility for Young Children in Low-Income and Middle-Income J. M. Meeks-Gardner, A. Powell Cam Rahman, and to determine whether permission is needed for Countries.” The Lancet 378 (9799): 1339–53. L. Richter. 2011. “Inequality in early childhood: Risk reuse and to obtain permission from the copyright owner. If you have questions, email pubrights@ Fernald, Lia, Ann Weber, Emanuela Galasso, and Lisy and protective factors for early child development”. worldbank.org. Ratsifandriha. 2011. “Socioeconomic Gradients and Lancet, 378: 1325–38. SKU K8737 5