Integrating nutrition and early

childhood development program

• Introduction
• Nutrition and development
• Brain development
• Nurturing and stimulation
• Intervention program
 2007

Over 200 million children under 5 years of age in LMICs

are not fulfilling their developmental potential
Due to poverty, stunting, and lack of psychosocial stimulation

2011

Advancing Early Childhood Development: from Science to Scale

 Risk varies significantly by low,
middle and upper-middle income countries
Europe & Central
Asia:
• 17% stunted
• 3% in extreme
Latin America poverty
and Caribbean :
• 15% stunted South Asia:
• 6% in extreme • 40% stunted
poverty • 28% in
extreme
Sub-Saharan Africa : poverty
• 39% stunted
• 50% in extreme
poverty
Advancing Early Childhood Development: from Science to Scale
Accumulation of adversity
• As the number of risk
Poverty

factors increases, the Nutritional deficiencies

severity of impact rises Food insecurity

High-crime communities
• Children in LMICs are
exposed to a greater Low-quality resources

number of risks Family stress

Child abuse and neglect

stunting has negative effects on development
• Stunting is associated with
– negative socio-emotional behaviors and poor cognitive
performance, including deficits in literacy, numeracy,
reasoning, and vocabulary
– Up to 46% less income earned as adults (Hoddinott et
al., 2008)
• less enthusiasm when they explored their environment,
were more apathetic and less happy, were fussier, and
cried more.
• malnourished children are more likely to be:
– older at school enrollment
– repeat grades
– be absent from school
– drop out of school
– fail at least one grade

decreased learning and lower wages in adulthood

Brain development
Sensitive periods: brain development
a window within which the effects of environmental
stimulation on brain structure and function are
maximized
Experience affects different
aspects of brain function in
different periods of life
Cell division
and
migration Hearing and sight: 3-4 months;
Language: 6 months-2 yrs;
Resolving problems: 7 months-10
years

Advancing Early Childhood Development: from Science to Scale

Brain Architecture is Built: Over Time, on going process

• “bottom-up”:
• basic  complex
capabilities
• predictable sequence
• foundation for learning,
behavior, physical and
mental health
 The Plasticity of Brain Architecture
• PLASTICITY refers to the brain’s unique ability to change in
response to experience
• Synaptic Plasticity
– Variation in the STRENGTH of individual connections
– Lifelong, but early childhood is genetically programmed
to produce more synapses than it will ultimately use
• Cellular Plasticity
– Variations in the NUMBER (or COUNT) of connections
– “Declines dramatically with age (waning by age 5)
 Brain plasticity decreases with age
• Brain circuits consolidate with increasing age, making them more
difficult to rewire
• The timetable of brain plasticity varies: it is narrow for basic
sensory abilities, wider for language, and broadest for cognitive and
social-emotional skills
• Early plasticity makes the young brain both more vulnerable to
harm and more capable of recovery
• "windows of opportunity"
• early interventions are more effective than later. Prevention is
less expensive than treatment
 Social, emotional, and cognitive
development are intertwined
• Emotional well-being and social competence provide a
strong foundation for emerging cognitive abilities 
foundation of human development.
• language: not only hearing, visual, cognitive but also
also on the ability to concentrate, pay attention, and
engage in meaningful social interaction
• Learning is an interactive process that depends on the
integration of multiple abilities and skills.
Factors influence shape the
developing brain

• Genetics
• experiences
• Environment
 Experiences- dependent
• Positives experiences increase synaptogenesis
• use it or lose it" (pruning)
– over-pruning”: when a child is deprived of normally
expected experiences in the early years
• Early experiences are foundational
 reciprocity interaction : serve and return
• Stress decrease neurogenesis, increase cell death
 Early Childhood Stress
Influences Developing Brain Architecture
• Stress  the body’s stress management systems: increase
– heart rate & blood pressure
– levels of stress hormones (e.g., cortisol)
– proteins associated with inflammation (e.g., cytokines)
• growth-promoting or seriously damaging depend on:
– Severity, intensity and duration of stress
– individual differences in children’s physiological
responsiveness to stress
– Supportive relationships adult/ caregivers
 Positive Stress
• Moderate, short-lived stress responses with supportive
relationship adults
– as brief increases in heart rate or mild changes in
stress hormone levels
• Precipitants: meeting new people, mastering separation,
getting an immunization, and coping with discipline
• An important and necessary aspect of healthy
development
 Tolerable Stress
• Stress responses that could disrupt brain
architecture, but are buffered by supportive
relationships that facilitate adaptive coping
– Generally occurs within a time-limited period,
which gives the brain an opportunity to recover
from potentially damaging effects
• Precipitants: death or serious illness of a loved one,
a frightening injury, or parent divorce
 Toxic Stress
• excessive and prolonged stress without buffering protection of
adult support
– Persistent elevation of cortisol disrupts brain architecture
(hippocampus) difficulty in learning, memory and self
regulation
• at relatively lower thresholds: Increasing
– the risk of stress-related physical (cardiovascular, DM)
– mental illness (depression, anxiety disorders, and substance
abuse)
• Precipitants: extreme poverty, physical or emotional abuse, chronic
and serious neglect, enduring maternal depression, family violence
 Early Stress

Source: Bruce Perry, MD, PhD, Child Trauma Academy

 Toxic stress

•Results in potentially permanent changes in:

• Gene expression (epigenetics)
• Brain development (neuroscience)
• Behavior (allostasis)
 environment
• Stable and responsive environment and
relationships:
– Provide consistent, nurturing and protective
interactions with adults/ care givers
• Safe and supportive physical, chemical and
built environments
• Appropriate nutrition
Nurturing and stimulation
Bonding
The process of a mother forming a relationship with her new
infant (mother/father to infant)

• Begins during the first few hours after birth

• Mother recognizes her child and “falls in love”
• Fathers may “fall in love” as well if they see their infant at
birth
Conditions that can undermine bonding
• Mother
– Separated from infant for a long period after birth
– Mother has mental, physical, or emotional problems
(Heneghan et al., 2000)

• Child
– Low birth weight (LBW) or disability
– Japanese study concluded that 43% of abused children
were LBW, often with more illness (Tanimura et al., 1995)
Attachment
The process of the infant forming a relationship with his or
her mother or father (infant to mother/father), and
reinforced by the responses of the mother/father
• Occurs in first two years of life, but especially between 2
and 7 months of age
• Child develops:
– A communication system with the primary caregiver
– A unique bond that provides a sense of security
– Self-confidence, well-being, and survival skills
Consequences of very poor attachment
Child feels deeply insecure
–Confusion (‘lost in a strange country without an
interpreter’)
–Lack of trust
–Rage or depression may increase
–Shutting down—’non-organic failure to thrive’
–Long–term effects on adult relationships
•When there is no primary caretaker or stable caregiver,
child may have difficulty adapting to change
 Basic Caregiving Skills:
Sensitivity and Responsiveness
• Sensitivity:
– The capacity of the caregiver to be aware of the
infant and aware of the infant’s acts and vocalizations
that communicate needs and wants
• Responsiveness:
– The capacity of the caregiver to respond
contingently, appropriately to the infant’s signals
• To be responsive, the caregiver must be sensitive
Sensitive and responsive care:
• Improves child’s chances of:
– good nutrition through responsive feeding
– good health through attentive care-seeking
– cognitive development through responsive language
and play
– Social and emotional development through nurturing
and love
• The basis for a child’s self-confidence and readiness to learn
 Responsive feeding
the caregiver to be attentive to the child’s cues of hunger and
satiety and her/his feeding needs and preferences; helps ensure
the child’s dietary intake is well matched to his/her needs; and
improves communication between the child and the caregiver,
which helps develop the child’s nonverbal and verbal
communication skills
 Parenting and nurturing care
• Nurturing care envelops early child development
• Comprises all essential elements for a
child to grow physically, mentally and Socially:
 Nutrition

 Health care

 Love and security

 Protection from danger

 Opportunities to learn and discover the world

Integration nutrition and ECD
program
Integration stimulation and nutrition

• Integrated nutrition and

ECD interventions have the
potential for greater
cumulative impact on
nutrition and ECD outcomes
compared to single-sector
interventions
 Effective interventions:
UNICEF/WHO Care for Child Development (CCD)
• Initially Developed as a Module of IMCI
• To be compatible with health service
delivery in LMICs
• Community workers trained to
encourage, model, prompt and praise
mothers/caregivers
• Expanded to 23 sites in 19 countries;
translated into 17 languages
The counseling approach in Care for Child Development
• Based on the model of nutrition counseling
– Targets children most at risk: children with anemia or low weight for age,
and all children less than two years

• Improves the knowledge and skills of mothers and other caregivers

– Strengthens active and responsive feeding to improve nutrition and
growth
– Introduces play and communication activities
• To improve interaction between caregiver and child
• To stimulate growth and learning
• And to promote responsive care for
the child’s health
– Helps solve problems in care
 How Care for Child Development
improves early child development
•Provide ways Interactions Tx •Look into your
for your child child’s eyes
to see, hear, and smile at
feel, and him or her.
move
•Respond to
•Give your your child’s
child clean, sounds and
safe things to interests
handle, bang, Activities Emotions
drop
Improved bonding (mother to child)
and attachment (child to mother)
for a sensitive, responsive, effective relationship
 Evidence of effectiveness
• China (2007) – two
counselling sessions
• Turkey (2008) – sick
child visit
• Pakistan (2010-2013) –
home visits and mother
groups
 Improving ECD is key to achieving the SDGs
GOAL CONTRIBUTION OF ECD TO ACHIEVING THE GOAL
1 Eradicate poverty ECD interventions increase school grades and earnings
2 End hunger and improve nutrition ECD and nutrition interventions help to improve early growth & development

ECD interventions improve quality of home practices, increase health service use and
3 Ensure healthy lives
decrease chronic disease and mental ill-health

4 Ensure lifelong learning ECD interventions promote learning, grade achievement and productivity

5 Achieve gender equality ECD interventions increase learning motivation, especially for girls

10 Reduce inequality among and ECD and nutrition interventions help children at risk to attain their developmental
between countries potential

16 Promote peaceful societies ECD interventions improve emotional regulation and social behaviour
17 Strengthen the means of
ECD interventions can strengthen coordination across sectors
implementation

Advancing Early Childhood Development: from Science to Scale

Improving ECD is key to achieving the SDGs

Advancing Early Childhood Development: from Science to Scale

 Development results from an on-going, re-
iterative, and cumulative dance between
nurture and nature
Experience
Protective and Personal
(versus Insecure and Impersonal)

Brain Development Epigenetic Changes

Alterations in Brain
Alterations in the Way the
Structure and Function
Genetic Program is Read
Behavior
Adaptive or Healthy Coping Skills
(vs. Maladaptive or Unhealthy Coping)
Source: AAP: Helping Foster And Adoptive Families Cope with Trauma. 2013.
The amazing journey of human development

A genetic blueprint in the

embryo/fetus establishes the
broad strokes of development

Environment modifies this

blueprint during critical
periods of development

Advancing Early Childhood Development: from Science to Scale

 Environments across the life-course

Parent’s
Pregnancy Environment in
Health/Wellbeing
Environment Infancy/Childhood Health
Pre-pregnancy

Learning

Genetic Blueprint for Development

Quality and timing of early environments shape a child’s future potential Behavior

Advancing Early Childhood Development: from Science to Scale

 Multi-generational impact of early environments
• Health of the mother
• Pregnancy environments impact multiple
genomes.
• The pregnancy contains the genomes of the
mother, the child and the grandchild.

• Health of the father

• Paternal pre-pregnancy health and well being
impacts the health and development of infants
and children.
 Gene environment interactions underlie
developmental programming
Development
Environment
Variations in
Genetic Adult Health and Wellbeing
Sequence Cardiovascular disease
Obesity/diabetes
Mental health
Epigenetic Cognitive function
Modification Behaviour/social function

Advancing Early Childhood Development: from Science to Scale

 Foetal
development

Life-course Inter-
generational
Infant & child
growth &

approach
effects
development

Adult health & Adolescent

human capital education &
health

Advancing Early Childhood Development: from Science to Scale