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SPECIAL ARTICLE
Building a strong foundation for healthy system, and other body organs, as well undernutrition in the preschool years
development during the early years as behavioral adaptations that have accounted for a loss of more than two
of life is an important prerequisite for lifelong impacts on learning, behavior, grades in school and .30% in later
lifelong well-being, successful commu- and health.4 Under conditions of ex- adult income.14 Poverty is also associ-
nities, economic productivity, and har- treme disadvantage, short-term physi- ated with higher levels of exposure to
monious civil societies.1,2 Stated simply, ologic and psychological adjustments stressful conditions linked to violence,
a promising future belongs to those that are necessary for immediate sur- poor infrastructure, and lack of serv-
nations that invest wisely in their youn- vival may come at signicant cost to ices.15,16 The longer poor children are
gest citizens. Increasing evidence indi- lifelong health and development. In- exposed to these destabilizing circum-
cates that the lifelong burden of early deed, there is extensive evidence that stances, the greater the risk that their
disadvantages can be difcult to re- the long-term consequences of depri- stress response systems become dys-
verse, whereas a good start helps vation, neglect, or social disruption can regulated, which leads to increased sus-
children develop capacities to cope suc- create shocks and ripples that affect ceptibility to illness, disability, impaired
cessfully and contribute to the socio- generations, not only individuals, and learning, and social maladjustment in
economic development of the society have signicant impacts that extend both the short and long term.1720
in which they live. Thus, as progress is far beyond national boundaries.5 The failure to address conditions that
made in reducing child mortality, par- limit the life prospects of young chil-
ticularly in the poorest countries that CONFRONTING THE HUMAN AND dren seriously undermines the social
carry the greatest burden of unfullled SOCIETAL TOLL OF POVERTY and economic development sought by
human potential, improving the life all nations.2123 Setting priorities for
Severe economic hardship and social
prospects of those who survive pres- mitigating the adverse impacts of pov-
adversity impose a cumulative burden
ents an equally compelling priority.3 erty, discrimination, and/or violence on
of risk on hundreds of millions of chil-
To this end, new knowledge in the children, however, is not a simple task.
dren around the world, a burden that
biological and social sciences can in- The imperative of reducing prevent-
undermines multiple dimensions of
form innovative strategies to address able deaths is fundamental, and the im-
their lives, including resources, safety,
threats to child survival and well-being, plementation of effective interventions
care, and opportunities. Growing up in
and improve adult outcomes, as well, within existing health care systems
impoverished or unsafe conditions is
in ways that did not exist as recently remains a challenge.2434 Equally im-
associated with signicant threats to
as a decade ago. portant, however, is the realization
long-term physical and mental health,
that the campaign to save lives is in-
Advances in the life sciences have cognitive development, educational
complete if the future prospects of
deepened our understanding of the achievement, emotional well-being, and
those who survive are constrained by
importance of dynamic interactions social adjustment, and these impacts
continuing adversity, particularly in
among environmental inuences (in- are particularly potent in early child-
the poorest countries. Thus, the time
cluding exposure to toxic chemicals), hood.610 Whereas poverty is measured
has come to mobilize science to both
social experiences (including the de- primarily in terms of material assets
increase child survival and promote
bilitating effects of poverty, population and purchasing power, associated so-
early childhood development.
displacement, unstable relationships, cial and psychological dimensions such
and exposure to violence), nutrition (in- as social exclusion, lack of empower-
cluding the consequences of both in- ment, and a sense of hopelessness THE EARLY CHILDHOOD ROOTS OF
adequate and excessive food intake), also undermine family dynamics, child- HUMAN CAPITAL
and genetic predisposition (including rearing practices, and human devel- In 1990, the United Nations Development
the extent to which experiences can opment.11,12 Program adopted the Human Develop-
inuence gene expression) in affecting The undernutrition linked to poverty is ment Index (HDI), which incorporates
both individual and population well- estimated to contribute to 35% of all a rough assessment of health and ed-
being. New discoveries in molecular child deaths due to measles, malaria, ucation along with income, as an alter-
biology and epigenetics are explain- pneumonia, and diarrhea, as well as to native to the Gross Domestic Product
ing how early adversity, as a result of stunted growth for .200 million chil- per capita as a measure of a countrys
scarcity, stress, or instability, can lead dren worldwide.13 A recent analysis of overall well-being.34 Ten years later, the
to physiologic disruptions in the de- longitudinal data from low- and middle- international community adopted eight
veloping brain, the cardiovascular income nations found that poverty and Millennium Development Goals (MDGs),
e462 SHONKOFF et al
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SPECIAL ARTICLE
the number of children who die be- complex circuits building on The most widely postulated biological
fore their fth birthday and represents simpler circuits and increas- explanation for these well-established
roughly one-third of all children under ingly complex and adaptive skills associations points to the long-term
age 5 in the world.14 The economic emerging over time. consequences of short-term adapta-
implications of these data are under- Cognitive, emotional, and social tions in neuroendocrine, autonomic,
scored by recent longitudinal analyses capacities are inextricably inter- immunologic, and neuropsychological
that reported signicant loss of edu- twined, and learning, behavior, and systems78 that are designed to cope
cation and adult earnings attributable both physical and mental health with immediate threat, yet become
to early undernutrition in ve low- and are highly interrelated over the life problematic in the face of excessive
middle-income countries.63 course. activation.4,79 Alterations in electroen-
cephalography tracings and elevated
BUILDING A COORDINATED, Although manageable levels of
levels of cortisol and norepinephrine in
SCIENCE-BASED APPROACH TO stress are normative and growth-
children exposed to repeated trauma
CHILD SURVIVAL, CHILD promoting, toxic stress in the early
and maltreatment are examples of
DEVELOPMENT, AND LIFELONG years (ie, the physiologic disrup-
such responses.65,80 Converging evi-
HEALTH tions precipitated by signicant
dence from epidemiology and neuro-
adversity in the absence of adult
Although full elucidation of the under- science also indicates that a variety
protection) can damage the devel-
lying causal mechanisms that explain of stresses in early life, including ad-
oping brain and other organ sys-
socioeconomic disparities in health and verse intrauterine inuences such as
tems and lead to lifelong problems
learning awaits further investigation, nutritional deciencies, can cause en-
in learning and social relationships
a rich and growing science of early during abnormalities in brain organi-
as well as increased susceptibility
childhood development is available to zation and structure, as well as in
to illness.
inform the design of more effective endocrine regulatory processes, that
interventions to both increase survival Brain plasticity and the ability to lead to reduced immune competence
for children born under conditions of change behavior decrease over and higher or less regulated cortisol
signicant disadvantage and improve time, so getting things right the levels, among other consequences.63,81,82
the life prospects of those who do not rst time is less costly, to society Extreme stress and fear in infancy can
die yet face extraordinarily high risks and individuals, than trying to x also result in later patterns of hyper-
for poor outcomes.1 To this end, the them later. vigilance and dysregulated relation-
National Scientic Council on the De- We have the capacity to measure ships that impair learning, socialization,
veloping Child64 proposed a concep- effectiveness factors that make the and productivity.78
tual framework that draws on the difference between interventions To fully understand the ways in which
following evidence-based principles: that work and those that do not survival, growth, learning, and health
The architecture of the brain is work to support healthy child de- are interrelated and undermined in com-
constructed through an ongoing velopment. parable ways by signicant adversity, it
process that begins before birth, The link between signicant adversity is essential to understand the central
continues into adulthood, and estab- in childhood and increasing risk for role of the brain in interpreting and
lishes either a sturdy or a fragile later disorders in physical and mental regulating the bodys neuroendocrine,
foundation for all the health, learn- health has been documented exten- autonomic, and immunologic respon-
ing, and behavior that follow. sively.4,6567 Low birth weight and poor ses to stressful events. Stated simply,
The interaction of genes and expe- infant growth, for example, are asso- the brain is the bodys central control
riences literally shapes the cir- ciated with a range of metabolic dis- center that inuences both physiologic
cuitry of the developing brain, and orders.68 Children who have been and behavioral responses to threat as
is critically inuenced by the mu- neglected, abused, or malnourished well as the development of coping
tual responsiveness of adult-child are more likely to have heart disease skills in the face of adversity.83 More-
relationships, particularly in the as adults.6973 They are also at greater over, the brain is not only an engine
early childhood years. risk for a variety of health-threatening of physiologic change in other organ
Skill begets skill as brains are behaviors such as smoking and sub- systems, but it is also itself a target
built in a hierarchical fashion from stance abuse, as well as depression of acute and chronic stress, both phys-
the bottom up, with increasingly and anxiety disorders.7477 ical and psychological, and therefore it
e464 SHONKOFF et al
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SPECIAL ARTICLE
maternal, newborn, and child health interventions. The successful imple- extent to which persistent scarcity,
had increased, funding for this sector mentation of these services requires stress, and social instability pose con-
accounted for only 31% of all devel- competent governance, functional facili- tinuing threats to the life prospects of
opment assistance for health in 2007.26 ties and supply chains, a well-trained and children must be a focus for more
In an effort to spur greater progress motivated health care work force, and proactive intervention.
toward meeting MDG goals in this area, additional resources.108 Increasing de- As the science of early childhood de-
the United Nations launched a Global mand through community engagement velopment (ECD) has received increas-
Strategy for Womens and Childrens and mobilization are other critically im- ing recognition globally, the demand
Health in 2010 with a stated objective portant factors inuencing maternal and for greater attention to the needs of
of saving 16 million lives by 2015.107 newborn care in poor countries.109 young children has been incorporated
The major causes of death under the Equally important, and deserving of into several high-prole international
age of 5 in the wealthiest nations increased attention, the biology of documents, including the World Decla-
currently include neonatal conditions, adversity suggests that social inter- ration on Education for All (EFA)110 and
congenital anomalies, motor vehicle ventions that reduce or mitigate the the Dakar Framework for Action,111 the
accidents, and cancer. The most com- physiologic consequences of toxic Millennium Development Goals, and
mon causes of childhood mortality in stress associated with signicant ma- the Report of the World Health Orga-
the poorest countries are diarrhea, terial deprivation (with or without the nization (WHO) Commission on Social
pneumonia, measles, and neonatal con- additional burdens of recurrent abuse, Determinants of Health.112 In 2006,
ditions, with undernutrition as a major chronic neglect, intrafamily and civic UNICEF reported that .30 low- and
underlying contributing factor. Malaria violence, and maternal depression) rep- middle-income countries had estab-
and HIV add signicant additional ca- resent a promising enhancement of lished national ECD policies, and .70
sualties in vulnerable areas. The cur- existing strategies for reducing early nations had some type of national com-
rent knowledge base driving the child childhood mortality. To this end, inter- mission to coordinate ECD programs
survival agenda is grounded in tradi- ventions focused on strengthening the across ministries and sectors.113 These
tional public health principles and the capacities of families to meet their calls for greater investment in young
demonstrated effectiveness of interven- childrens needs in the face of desti- children have been buttressed by in-
tions such as the provision of adequate tution or threat suggest two causal creasing evidence of the effectiveness
nutrition, clean water, sanitation, and pathways to prevent premature death. of early childhood interventions on a
basic medical care; promotion of early The rst is predicated on more effec- range of health and developmental
and exclusive breastfeeding; immuni- tive utilization of preventive and ther- outcomes in low- and middle-income
zation, oral rehydration therapy, and apeutic health services. The second is countries.29,114,115 Within this increas-
vitamin A supplementation; the use of based on the protective inuence of ingly receptive environment, advances
insecticide-treated bed nets to prevent parents ability to promote greater in the biology of adversity offer con-
malaria; and prevention and treat- resilience in their children by facilitat- siderable promise as an additional
ment of HIV/AIDS. Table 1 provides a list- ing effective coping mechanisms in the catalyst to help stimulate the design
ing of recent reviews of interventions face of adversity. and testing of coordinated strategies
designed to improve maternal, new- Building on these efforts, as child mor- to further reduce preventable death
born, and child health and nutrition. tality rates continue to fall, the founda- and to build a foundation for a life-
While it is clear that continuing bio- tional importance of the early childhood time of healthy development.24,32,63,116135
medical research will advance our period for lifelong health and develop- When viewed through this broader
ability to further reduce mortality on ment suggests that survival alone can lens, current medically based inter-
a global scale, important challenges to no longer be a sufcient goal, espe- ventions that are designed primarily to
child survival in the developing world still cially for the poorest countries. Indeed, improve maternal and child survival
remain within the realm of political will the scientic concepts outlined in this are also likely to have positive inuen-
and effective delivery of basic nutrition, article suggest a common underlying ces on child development, yet these
sanitation, and personal health services. vulnerability that leads to a continuum outcomes have not been measured in
These challenges are manifested in the of risk, from early mortality through most evaluations of such programs.
need for existing health systems to deliver a broad spectrum of compromised For example, antenatal services for
an effective combination of health promo- learning as well as impairments in both women that lead to lower rates of in-
tion, disease prevention, and therapeutic physical and mental health. Thus, the trauterine growth retardation24 result
SHONKOFF et al
interventions but no delivery
strategies
WHO review of practices that promote Children under age 5 Review of evidence for 12 key practices 12 key practices Underscored importance of linking
child survival, growth, and identied by UNICEF and WHO practices at community level with
development (2004)31 service availability
Lancet review of neonatal outcomes Newborn mortality Community-based interventions review 43 interventions 16 newborn interventions packaged into
(2005)28 (few RCTs) three delivery strategies (community,
outreach, and facility levels)
Lancet review of maternal survival Maternal mortality and morbidity Literature and program review 120 interventions Recommended facility-based skilled
(2006)27 (few RCTs) care at childbirth as the core
intervention
Review of maternal and perinatal Maternal care Literature review and component 84 interventions 5 intervention packages considered
priorities in developing countries analysis for cost-effectiveness (with or without nutritional
(2006)30 supplements)
Lancet review of child development Child and adult cognitive and other Literature and program review 20 programs Recommendation to integrate early child
programs (2007)29 developmental outcomes (few RCTs) stimulation and nutrition programs,
and evaluate at scale
Lancet review of maternal, newborn, Maternal, newborn, and child mortality Literature and delivery strategy review 190 interventions 8 packages of interventions targeted at
and child care (2007)33 for interventions across continuum four levels (household and
of care community, outreach, upper and
lower level facilities)
Lancet review of undernutrition (2008)24 Maternal, newborn, child, and adult Literature and program review 45 interventions Maternal nutrition and supportive
mortality and morbidity due to (RCTs and observational studies) interventions targeted to children
undernutrition during the rst 24 months
Lancet review of primary health care Interventions relevant to maternal, Literature and program review 156 interventions 37 key interventions recommended for
(2008)25 newborn, and child survival and (RCTs & observational studies) inclusion in primary care settings
selected key risk factors
Lancet review of countdown to maternal, Focus on maternal, newborn, and child Review of relevant information from 22 interventions and Better coverage seen with
newborn, and child survival goals survival-related interventions and DHS and MICs data sources respective coverage programmable interventions such as
(2010)26 tracking coverage EPI vaccinations, vitamin A
supplementation, etc.
Lancet review of stillbirths (2011)34 Focus on strategies to inuence fetal Comprehensive review of available 35 interventions 10 evidence-based interventions
in the birth of babies who are at lower childhood intervention by Sameroff lower prevalence of later welfare de-
risk biologically for developmental and Fiese138; the ecological model ar- pendence and incarceration,1 the evi-
impairments. Another example is pro- ticulated by Bronfenbrenner139; and the dence base for successful intervention
vided by interventions that promote concepts of vulnerability and resilience across a broad diversity of nations is
breastfeeding to enhance both nutri- developed by Werner and Smith,140 growing.
tional status and immunologic compe- Garmezy and Rutter,141 and Rutter.142 In low- and middle-income countries,
tence,32,119,125 which are also likely to Together, these frameworks underscore model programs that combine nutrition
promote early developmental progress the extent to which life outcomes are and psychosocial stimulation services
by strengthening maternal-infant inuenced by a dynamic interplay be- have demonstrated the greatest impact
attachment. In a reciprocal fashion, tween the cumulative burden of risk on disadvantaged populations.145 A re-
strategies that focus explicitly on factors and the buffering effects of view of 20 programs that met rigorous
strengthening caregiver-child inter- protective factors that can be identied scientic criteria found that all but
actions and expanding early learning within the individual, family, commu- one (which was delivered at a very low
opportunities in the face of signicant nity, and broader socioeconomic and level of intensity) had positive effects
material deprivation are likely to re- cultural contexts. Each of these models on childrens cognitive development,
duce or mitigate the biological impacts also emphasizes the inuence of re- whereas some also reported gains in
of adversity on very young children, ciprocal child-adult interactions in the social competence, with effect size esti-
thereby enhancing both their survival developmental process, thereby under- mates ranging from 0.3 to1.8.29 A more
and their development. scoring the importance of stable and recent meta-analysis of evidence from
Although the underlying science that nurturing relationships and recognizing 30 interventions utilizing a variety of
supports investment in early child- the active role that young children play approaches in 23 countries in Europe,
hood development has advanced con- in their own development. The chal- Asia, Africa, and Latin America also
siderably, and the literature on effective lenges of actually applying this multi- found moderately positive effects across
demonstration projects in low-income dimensional framework include both multiple developmental domains.146 Of
countries is growing, empirical evidence avoiding the lure of simplistic solutions the models studied, eight provided early
of the successful scale-up of specic and making strategic decisions about education, ve provided child care,
interventions across national and cul- which factors to address and which to ve focused on nutrition, four combined
tural settings is less well developed. omit in designing a specic policy, pro- nutrition and early education, two linked
Moreover, EFA Goal 1 addresses early gram, or empirical study.143 nutrition and child care, one provided
childhood objectives, yet it is the only In response to these challenges, early both early education and child care,
education goal without a quantiable childhood intervention services typically and six focused primarily on cash
indicator against which progress can include nutrition supplements, basic transfers. On average, the magnitude
be measured.136 Similarly, more than health services, and a combination of of the long-term effects was about
half of the worlds governments have nurturing care and enriched learning one-quarter to one-third of a SD, with
ECD policies that are statements of in- opportunities for children, linked to cognitive impacts at the higher end
tent rather than enforceable mandates. a mix of parenting education, emotional (particularly in programs with an ex-
These concerns are compounded by the support, and social protection and so- plicit education component) and posi-
limited number of major international cial services for their families. Over four tive effects sustained through adulthood
donors who have identied ECD as decades of program development and when long-term data were obtained.114
a specic focus, the majority of whom evaluation, this approach has been Recent modications of conventional
allocate ,2% of their education fund- implemented in demonstration projects ECD programs have included greater
ing to the early childhood years.136 around the world that have conrmed attention to nancial and social pro-
Over the past several decades, early the ability to produce signicant impacts tection for parents, increasing focus
childhood policies and practices have across a range of outcomes.144 Although on confronting violence against women
been guided by several theoretical mod- much of the empirical literature has and young children, and the promo-
els of human development that have come from the United States, where tion of positive engagement of men in
been rened over time. These include positive returns on investment have addressing family needs. These and
the transactional model formulated by been documented in cost savings from other program models have been
Sameroff and Chandler137 and later decreased grade retention and refer- delivered through a variety of mecha-
adapted to the challenges of early rals for special education as well as nisms including home visiting, primary
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e472 SHONKOFF et al
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An Integrated Scientific Framework for Child Survival and Early Childhood
Development
Jack P. Shonkoff, Linda Richter, Jacques van der Gaag and Zulfiqar A. Bhutta
Pediatrics 2012;129;e460
DOI: 10.1542/peds.2011-0366 originally published online January 4, 2012;
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright 2012 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .