Clean, Fed & Nurtured: Joining forces to promote child growth and development
WASH and
Child Growth & Development
Washington, DC | May 2-3, 2013
Val Curtis
London School Of Hygiene and Tropical Medicine
& Alan Dangour, Oliver Cumming, SHARE, DFID
WASH basics
• Water
– quantity and quality
• Sanitation
– Faecal waste
disposal
• Hygiene
– Hand, Food,
Environment
0.85m
deaths a
year
2-3.5bn
episodes
Source: Liu et al, Lancet 2012
Fluids
Fields
Faeces
Foods
Flies
Fingers
New
Host
Fluids
Fields
Faeces
Foods
Flies
Fingers
New
Host
Fluids
Fields
Faeces
Foods
Flies
Fingers
New
Host
Fluids
Fields
Faeces
Foods
Flies
Fingers
New
Host
Fluids
Fields
Faeces
Foods
Flies
Fingers
New
Host
Fluids
Fields
Faeces
Foods
Flies
Fingers
New
Host
Fluids
Fields
Faeces
Foods
Flies
Fingers
New
Host
2.6bn have no safe toilet
0.8bn have no safe drinking water
20%?? HWWS
Source: Global Water Supply and Sanitation Assessment 2010 Report: WHO and UNICEF, 2012
WASH and nutrition
Poor WASH
Faecal-oral exposure
Environmental
Enteropathy
Nematode
infection
Diarrhoeal
Diseases
Poor nutritional status
Cochrane Public Health Group
• Includes
– RCTs
– non-randomised controlled studies
– interrupted time series studies
• WASH included as one intervention
Review protocol
• All included studies to have controlled design
• Participants: children < 18 years old
• Intervention types
– Improving access to facilities which ensure the hygienic
separation of human excreta from human contact
– Promotion of hand washing with soap
– Introducing a new/improved water supply and/or improved
distribution
– Improving the microbiological quality of drinking water
Outcomes, search strategy
• Primary outcomes (z-scores)
– Weight-for-height (wasting)
– Weight-for-age (underweight)
– Height-for-age (stunting)
• Secondary outcomes
– All other child anthropometric measures
– Biochemical measures of micronutrient status
• 6 databases searched; keyword and MeSH terms
• 3 main Chinese databases searched
Search results
Included studies
• 12 studies from 10 countries
–
–
–
–
–
–
–
–
–
–
Bangladesh (1989; 1993)
Guatemala (1968; 2009)
Pakistan (2012)
Kenya (2011)
Ethiopia (2012)
Nigeria (1990)
Nepal (2011)
Chile (1983)
South Africa (2010)
Cambodia (2011)
• Duration: 6 mo to 5 years
• Sample: n=8,500; all <5 years
Interventions
• Studies included from 1 to 4 WASH interventions
• Interventions
–
–
–
–
–
–
–
–
Provision of flocculent water disinfectant
Provision of a protected water supply
Installation of boreholes and hand pumps
Solar water disinfection (SODIS)
Sanitation education
Construction of sanitary facilities
Provision of soap
Promotion of hand washing with soap
Study designs
• Multiple designs
–
–
–
–
–
–
Randomised controlled trials (3)
Follow-up of cluster randomised controlled trial (1)
Longitudinal study with control group (3)
Repeat cross-sectional with control group (3)
Controlled before-and-after study (1)
Cross-sectional with intervention and historic control group
matched by propensity score matching (1)
• No study considered high quality according to Cochrane
criteria
Results table n=8,500
Study
n
Reported effect (HAZ unless stated)
Ahmed 1993
298
Mean WAZ: P< 0.05
Arnold 2009
877
MD: 0.04 (-0.19, 0.27)
Bowen 2012
461
MD: -0.08 (-0.29, 0.13)
Du Preez 2010
329
MD: 0.15 (-0.14, 0.44) (not published)
Du Preez 2011
521
MD: 0.12 (-0.15, 0.39)
Fenn 2012
1899
MD: 0.22 (0.11, 0.33)
Guzman 1968
N.D.
Mean height: no stat. test
Hasan 1989
405
No statistically different differences
Huttly 1990
180 – 368 Decline in % children with low W/H: P<0.005
Langford 2011
88
MD: -0.13 (-0.54, 0.28)
McGuigan 2012
753
MD: 0.18 (-0.06, 0.42) (not published)
Schlesinger 1983
199
% low weight: P<0.05 for change in control group
HAZ (all studies)
HAZ meta-analysis n=1,603
I2 = 0%
WAZ meta-analysis n=1,616
I2 = 5%
WHZ meta-analysis n=1,605
I2 = 0%
Interpretation
• Number of children included in studies reasonable
• Quality of studies is limited
• Cochrane meta-analysis suggests that WASH improves
HAZ by ~0.15 SD
• Supported by IPD analysis
• “Suggestive evidence of benefit”
Concerns
• Publication bias
• Quality of studies
• Links in the pathway?
Conclusions of Cochrane review
•
•
•
•
•
First systematic review of WASH and nutrition
12 studies (of mixed quality) provide data for analysis
Suggestive evidence of benefit of WASH on linear growth
More evidence on the way
And still more needed!
WASH and nutrition
Poor WASH
Faecal-oral exposure
Environmental
Enteropathy
Nematode
infection
Diarrhoeal
Diseases
Poor nutritional status
Diarrhoea and stunting
• Diarrhoea associated with poor nutritional status
but causal link hard to demonstrate
• Poor nutritional status associated with greater risk
of diarrhoea (Briend, 1990; Checkley et al, 2002)
• Recent analysis of 9 studies with daily diarrhoea
morbidity data and longitudinal anthropometry
(Checkley et al, 2008):
– Odds of stunting at age 24 mo increased with each diarrhoeal episode
before 24 mo (P<0.001)
– Odds of stunting at age 24 mo increased by 1.13 (95% C.I. 1.07, 1.19) for
every five episodes
– Consistent with hypothesis that higher cumulative burden of diarrhoea
increases risk of stunting
WASH and nutrition
Poor WASH
Faecal-oral exposure
Time, costs,
workload
Environmental
Enteropathy
Nematode
infection
Poor nutrition
Diarrhoeal
Diseases
Other
Diseases
WASH and ECD
Poor WASH
Faecal-oral exposure
Time, costs,
workload
Environmental
Enteropathy
Nematode
infection
Poor ECD
Diarrhoeal
Diseases
Other
Diseases
Diarrhoea/Giardia and ECD
High diarrheal disease burdens before 2 years of age linked with
delayed school entry and poorer performance on intelligence
tests
– Patrick et al 2005.
– Lorntz et al 2006
Multiple infections with Giardia associated with a 4-point (0.27
SD) deficit on a standardized intelligence test at 9 years of
age.
– Berkman et al 2002
Bowen et al 2012...
“At 5 to 7 years of age, children randomized to home-based
handwashing promotion during their first 30 months of life
attained global developmental quotients more than 6
points (0.4 SD) greater than control children.
The effect size was similar across all 5 domains (adaptive,
personalsocial, communication, cognitive, and motor)
...and is comparable to gains after participation in the US
publicly funded Head Start preschool program for poor
children (SD, 0.33-0.46 compared with parental care) and
early intervention programs for premature infants (SD,
0.46)
Such an effect size is regarded as clinically meaningful and
some estimate that a societal shift of this magnitude would
yield trillions of dollars in increased productivity.”
Conclusions
• Systematic reviews are blunt instruments but
the best we have
• All studies need publishing
• Ever more evidence to collect? Should that
hold us back?
• Is this about competition?
Clean, Fed & Nurtured: Joining forces to promote child growth and development
NUTRITION and
Child Growth & Development
Washington, DC | May 2-3, 2013
Kay Dewey
UC-Davis and Alive & Thrive
Nutrition Basics
• IYCF = infant and young child feeding, to 2 years
• WHO-recommended feeding practices for:
– Breastfeeding (early initiation; exclusive BF; continued BF)
– Complementary feeding (e.g. amount, consistency, frequency,
diversity & types of foods), including:
• Safe preparation & storage of complementary foods (relevant to WASH)
• Responsive feeding practices (relevant to ECD)
• Established indicators:
– Feeding practices (8 core WHO/UNICEF indicators)
– Anthropometric measures (e.g., weight for age, height for age,
weight for height, arm circumference)
• Reduction in stunting (very short height for age) is a key goal
Key window for nutrition interventions
Preconception through
pregnancy
0-6 mo: Exclusive
breastfeeding
6-24 mo: Complementary
feeding
Guiding principles
for complementary
feeding (2003; 2005)
Outline
• Impact of nutrition interventions on linear
growth (child’s height)
• Impact of nutrition on child development
• The need for combined interventions
Impact of nutrition on
child growth
Prenatal nutrition interventions
• Iron & folic acid supplements
• Multiple micronutrient
supplements
• Balanced protein-energy
supplements
• Fortified foods for pregnant
women
• Potential for major impact on
stunting, but evidence is mixed
Prenatal nutrition interventions
A. Multiple micronutrient supplements (usually
compared with iron & folic acid)
Meta-analysis in 2009 (Fall et al.):
•
•
•
Small but significant increase in birth weight (+22 g) but not birth
length (+0.06 cm)
– Measurement issues?
11-17% reduction in low birth weight
Impact only evident in mothers with higher BMI
Meta-analysis in 2012 (Ramakrishnan et al.):
•
•
Increase in mean birth weight (+53 g); data on birth length not
presented
14% reduction in low birth weight
Prenatal nutrition interventions
B. Balanced protein-energy supplementation
Meta-analysis in 2003 (Kramer & Kakuma):
•
•
•
Increase in mean birth weight (+38 g) but not birth length (+0.1
cm)
32% reduction in small-for-gestational-age births
Larger effect on birth weight in hungry season and in
undernourished women
Meta-analysis in 2012 (Imdad & Bhutta):
•
•
•
Increase in mean birth weight (+73 g); did not report birth length
32% reduction in LBW and 34% reduction in SGA births
Larger effect on birth weight in undernourished women
Prenatal nutrition interventions
C. Fortified foods for pregnant women
Lipid-based nutrient supplement (LNS)
(Huybregts et al. Am J Clin Nutr 2009), Burkina Faso
• LNS: 373 kcal/d & similar micronutrients as MMN tablets
• LNS group (compared to MMN):
– Birth weight +31 g (p=0.2)
– Birth length +0.46 cm (p=0.001)
• effect greater in mothers with BMI < 18.5 (+1.2 cm)
• Same research group previously showed that MMN (vs.
control) increased birth length by 0.36 cm; thus predicted
impact of LNS vs. control would be 0.46 + 0.36 = 0.82 cm
(effect size 0.33)
Exclusive breastfeeding 0-6 mo
• Large impact on infant survival
• Little evidence of impact on stunting
– Effect may be more likely in populations
with high rates of infection during the first
6 mo postpartum, where promotion of
exclusive breastfeeding may reduce
infection and thus be more likely to
promote linear growth than in
populations where such infections are
less common
– Insufficient evidence to evaluate this
question at present
46
Complementary feeding 6-24 mo
• Several strategies:
– Educational approaches
– Increasing energy density
of complementary foods
– Provision of
complementary food
– Fortification
6-24 mo: Complementary
feeding Guiding principles for
complementary
feeding (2003; 2005)
• Potential for major impact
on stunting but evidence
is mixed
47
Complementary Feeding - 1
• Educational approaches – mixed results
– Most showed little or no impact
– Peru study illustrated substantial potential to
improve linear growth (Effect size=0.5):
emphasized consumption of nutrient-rich animalsource foods & was conducted in a population
where animal-source foods were available &
affordable
– Two recent studies (Shi et al.; Vazir et al.) show
modest impact (Effect size ~0.2): both emphasized
key messages including dietary diversity and
animal-source foods
Complementary Feeding - 2
• Interventions to increase energy density –
mixed results
– Of 5 studies, 2 had positive impact but 3 had no
impact on energy intake or growth
– May be effective when traditional complementary
food has low energy density & infant unable to
compensate by increasing volume of food
consumed or feeding frequency
Complementary Feeding - 3
• Provision of complementary food – mixed
results
– Average effect size ~0.2-0.3, but wide range
• May depend on food security of target population
• May depend on nutrient quality of food provided
– Two studies directly compared food + education vs.
education only (both in S Asia): somewhat greater
impact when food included
Complementary Feeding - 4
• Fortification (or improved bioavailability) alone
has little effect on linear growth
– Exception: fortified vs. unfortified milk powder in India
• Combination of macro- and micro-nutrients in
may have a larger impact
• Nutrient quality of fortified products is likely to
be important
– Amount and bioavailability of nutrients needed for
growth
– Inclusion of milk
– Essential fatty acids
Summary of impact of nutrition
interventions on stunting
• Nutrition interventions (alone) have had a
modest impact on linear growth
– Need to be realistic about expected impact of
nutrition interventions
• However, impact on % with very low height
(stunting) may be larger than effect on mean
height
Impact of nutrition on
child development
Potential mechanisms for the effect of nutrient deficiency on
children’s
cognitive, motor, and socio-emotional development
From: Prado & Dewey, A&T Technical Brief
Nutrition and Brain Development in Early Life
(Prado & Dewey, A&T Technical Brief)
1) Adequate nutrition during pregnancy and the first two years is
necessary for normal brain development, laying the foundation for
future cognitive and social ability, school success, and productivity.
2) Priority should be given to the prevention of:
• Severe acute malnutrition
• Intrauterine growth retardation
• Stunting
• Iron-deficiency anemia
• Iodine deficiency
Nutrition and Brain Development in Early Life
(Prado & Dewey, A&T Technical Brief)
3) There is growing evidence for beneficial effects on ECD of:
• Breastfeeding promotion
• Pre- and post-natal multiple micronutrient supplementation
• Pre- and post-natal supplementation with essential fatty acids
• Fortified food supplements provided during pregnancy and to
the child from 6 to 24 mo
4) An integrated approach is likely to be most effective for
promoting optimal child development, i.e., interventions that
combine improved nutrition with other strategies such as
enhancing the home environment and the quality of caregiverchild interaction.
The need for
combined interventions
 Nutrition, infection control & care
 Prenatal + postnatal (and possibly pre-conception)
 Macronutrients + micronutrients: Adequate supply of
macronutrients may be needed to ensure growth response to
micronutrients
How nutrition can reduce the negative impact of
infections on child growth
1. Strengthening the immune system, thereby reducing the
severity and duration of infections
2. Providing extra amounts of nutrients to compensate for poor
absorption during infection, losses during diarrhoea,
reallocation due to immune system activation or reduced
appetite during infection
3. Providing nutrients for catch-up growth following infection,
particularly those needed to build lean body tissue such as
protein, potassium, magnesium, phosphorus, zinc and sodium
4. Preventing poor appetite caused by micronutrient
deficiencies, thereby facilitating catch-up growth
5. Favoring the growth of beneficial bacteria in the gut that
enhance gut function and immune defenses
Trials with combined nutrition + infection
control are underway
• WASH Benefits (water, sanitation and hygiene
interventions: singly, combined or in
combination with nutrition intervention)
• SHINE (independent and combined effects of
improved water, sanitation and hygiene and
improved infant feeding)
Both target mainly the postnatal period
Little evidence on impact of combined preand postnatal nutrition interventions
• Key trials conducted in 1970s
• INCAP trial in Guatemala
– Fortified food (atole) with high milk content
• Bogota study in Colombia
– Child’s food ration included milk
• Intervention trial with fortified food
supplements provided both pre- and
postnatally not attempted since
Trials with combined pre- and postnatal
nutrition are underway
• iLiNS Project: iLiNS-DYAD trials in Malawi and Ghana
– Efficacy of maternal LNS given during pregnancy & first 6
mo postpartum + child LNS given 6-18 mo
• The Early Nutrition and Immune Development (ENID)
Trial in the Gambia
– Efficacy of prenatal and infancy nutritional
supplementation, focused on infant immune development
• Rang-Din Nutrition Study in Bangladesh
– Program efficacy study with 4 arms – one arm includes
maternal LNS given during pregnancy & first 6 mo
postpartum + child LNS given 6-24 mo
Next steps?
• Evaluate impact of combined prenatal and
postnatal nutrition, ECD enrichment and
prevention/control of infection throughout
the 1000 days
– Efficacy
– Effectiveness
• Understand role of pre-conception nutrition
(trials underway)
• Understand role of maternal mental health
Clean, Fed & Nurtured: Joining forces to promote child growth and development
Early Child Development
Washington, DC | May 2-3, 2013
Maureen Black, Ph.D.
University of Maryland School of Medicine
Objectives
• Define Early Child Development
• Threats to Early Child Development
– Toxic Stress
– Undernutrition
• Development of Disparities & Lifespan Perspective
• Early Child Development Interventions
– Early Learning Opportunities & Responsive Caregiving
• Integrated Interventions
Early Child Development Basics
• Early Child Development
– Orderly progression of skills, based on maturation &
adaptation to specific culture/settings
– Direct and Indirect relationships
– Confusion: ECD refers to the intervention and the outcome
Social-Ecological Theory of Child
Development
Distal threats and
opportunities reach the
child through
Proximal interactions
between child & family
Bidirectional
interactions
Bronfenbrenner & Ceci, 1994
Child Development:
Multiple Contributing Factors
Health
Nutrition
School and
Community
Learning
Nutrition is necessary Services
for
Protection
Opportunities
from Stress/child development, but Family
Harm
not sufficient!
Support
Sensitive/
Social
Responsive
Protection
Caregiving
Threats to Early Development
• Poverty and Undernutrition
• Toxic stress
• Children can handle, even benefit, from mild stress
• Toxic stress
• Institutionalization, maltreatment, neglect, trauma,
undernutrition
• Lack of caregiver responsivity
Shonkoff , Pediatrics, 2012
How Toxic Stress Undermines Child
Development
• Non-reversible changes to children’s
physiology
– Dysregulation of neuroendocrine system
• Hypothalamic Pituitary Adrenal (HPA) Axis
• Elevated cortisol production
– Disrupt inflammatory signaling
• Increased susceptibility to illness
Johnson et al., Pediatrics, 2013; 131:319-327
Parent Nurturance/Responsivity
Buffering effects of
nurturant parenting
Johnson et al., Pediatrics, 2013; 131:319-327
Hippocampal volume by preschool
depression severity & maternal support
Maternal support in early childhood
predicts larger hippocampal volumes
at school age.
Positive, responsive relationships can
alleviate negative effects of stress
(brain structure/function).
Luby, PNAS, 2012;109(8):2854-9
Developmental Perspective
1000 days
Fetus
Late Infancy/Toddler
Pubertal
Thompson & Nelson, 2000
Developmental Perspective
1000 days
Fetus
Iron:
0.27 mg/day
0–6 months
Late Infancy/Toddler
11 mg/day
6-12 months
Pubertal
7 mg/day
1-3 years Thompson & Nelson, 2000
Developmental Perspective
1000 days
Fetus
Iron:
0.27 mg/day
0–6 months
Late Infancy/Toddler
11 mg/day
6-12 months
Pubertal
7 mg/day
1-3 years Thompson & Nelson, 2000
Development of disparities &
lifespan perspective
Development of disparities &
lifespan perspective
2007 & 2011
Lancet Series on Child Development
• Over 200 million children < age 5 y in low & middle income
countries do not reach developmental potential
– Nutrition: Chronic undernutrition, micronutrient deficiencies
– Lack of early learning opportunities
– Extended to social & environmental risks
• Efficacy of early interventions
– Early childhood policies & programs to reduce inequalities
– Cost of not investing in child dev programs
– Need for policies/procedures to scale up
www.globalchilddevelopment.org
Target of Interventions
• Prenatal
– Prevent Toxic stress/LBW/Prematurity
• Infancy
– Breastfeeding, complementary feeding
– Responsive Parenting
– Opportunities for early learning
– Routines to promote regulation
– Family support
Kramer et al., 2008; 2007 & 2011 Lancet series on Child Development
Early Child Development Intervention
• Early learning opportunities
– Play
– Explore
– Interactions: give & take/serve & return
• Responsive Caregiving
–
–
–
–
Recognize & interpret child’s cues
Prompt
Developmentally appropriate
Enriching
– Basis for responsive feeding
Black & Aboud, 2012
PROMOTES HEALTHY EATING & GROWTH
PATTERNS
RESPONSIVE FEEDING BEHAVIORS
Ummm,
maybe she is
telling me
she wants to
feed herself.
Caregiver
offers a bite
of food
Child
opens
mouth &
accepts
…………
Caregiver
offers another
bite
Child
looks away,
mouth
shut
………
………...Time…
PROMOTES HEALTHY EATING & GROWTH
PATTERNS
RESPONSIVE FEEDING BEHAVIORS
Caregiver
offers a bite
of food
Child
opens
mouth &
accepts
…………
Caregiver
offers another
bite
Caregiver
waits, smiles,
finger food
Child
looks away,
mouth
shut
Child
picks up food
& eats
………
………...Time…
HINDERS HEALTHY EATING & GROWTH
PATTERNS
NON-RESPONSIVE FEEDING BEHAVIORS
Oh no, I am
late. She has
to finish
eating.
Caregiver
offers a bite
of food
Child
opens
mouth &
accepts
…………
Caregiver
offers another
bite
Child
looks away,
mouth
shut
………
………...Time…
HINDERS HEALTHY EATING & GROWTH
PATTERNS
NON-RESPONSIVE FEEDING BEHAVIORS
Caregiver
offers a bite
of food
Child
opens
mouth &
accepts
…………
Caregiver
offers another
bite
Caregiver
holds child &
force feeds
Child
looks away,
mouth
shut
Child
Cries & spits
out food
………
………...Time…
Responsive/Unresponsive Feeding
RESPONSIVE
• Provides healthy food on a
regular schedule in a setting
conducive to eating
• Caregiver reads infant cues of
hunger/satiety
• Responds to infant quickly
– Direct & Nurturant
– Builds regulatory skills
UNRESPONSIVE
• Controlling, indulgent, or
uninvolved
• Ignores/overrides infant
cues
• Associated with
⁻ Difficult temperament
⁻ Maternal mental health
symptoms
⁻ Poor growth (under or
overweight)
Parenting interventions (0-3 yrs)
• Home visits, guidance and support from
health providers, and group parent training
• Impacts are larger when:
– parents and children participate together
– interventions involve modeling and practice of
behavior
– most disadvantaged children targeted
Lancet series on child development, 2007, 2011
Preschool interventions (3-5 yrs)
• Preschools improve children's cognitive & socialemotional development: school readiness
• Impact is greatest with high quality programs
– Teacher-student ratio
– Developmental curriculum
– Student exploration
– Teacher responsivity
Lancet series on child development, 2007, 2011
Characteristics of Successful Programs
• Integrated across sectors
• Focus on disadvantaged children
• Parents as partners with teachers to support children’s
development
• Opportunities for children to initiate learning & play
• Blend traditional child care, cultural beliefs & evidencebased practices (curriculum, materials)
• Systematic in-service training, supervision, monitoring,
and evaluation
Lancet series on child development, 2007, 2011
How do Integrated Programs Work?
Intervention
Child Devel
Child Development
SocialEmotional
SensoriMotor
Cognitive/
Language
Direct effect of child development intervention
Lancet series on child development, 2007, 2011
How do Integrated Programs Work?
Intervention
Child Development
SocialEmotional
Nutrition
SensoriMotor
Direct effect of nutrition intervention
Cognitive/
Language
How do Integrated Programs Work?
Intervention
Child Devel
Nutrition
Child Development
SocialEmotional
SensoriMotor
Cognitive/
Language
Additive effect of child development & nutrition intervention
Cognitive test score
Nutritional Supplementation and ECD
Intervention in Jamaica
115
110
105
100
95
90
85
80
Nonstunted
Control
Control
ECD
Intervention
Supplemented
Both
Grantham McGregor et al., 1991
DQ/IQ Stunted and Non-stunted Children
in Jamaica: Effects of ECD Intervention
0.8
0.6
SD Score
0.4
0.2
0
-0.2
Non-stunted
Stunted - ECD
Stunted - ctl
-0.4
-0.6
A = 9-24 mos, B = 33-48 mos, C = 7-8 yrs, D = 11-12 yes, E = 17-18 yrs.
Walker et al., 2005
How do Integrated Programs Work?
Intervention
Child Devel
Nutrition
Child Development
SocialEmotional
SensoriMotor
Cognitive/
Language
Synergistic effect: Impact of 2 interventions greater than their sum.
One intervention enhances the impact of the other intervention.
Tested with an interaction term.
Example of Synergistic Intervention
The effect of zinc supplementation onhand-eye coord.
enhanced by participation in a stimulation intervention.
Meeks Gardner et al., AJCN, 2005
Integrated Interventions
Rationale
• Same sites
• First 1000 days
• Overlapping goals
• Economy of scale
• Home/clinic visit –
integrated messages
• Theory-based
conceptualization
•
•
•
•
•
Considerations
Sectors differ
(education & nutrition)
Child development
beyond 1000 days
Overwhelm health
care/nutrition system
Overwhelm caregivers
Outcome??
Integrated Interventions
Questions
• Timing & severity of deprivations: Both
nutrition and child development
• Timing, intensity, & duration of interventions
• 1000 days? Beyond?
• Training and Supervision: Ensure integration?
• Outcomes and analytic models
• Policies and integration across sectors
• Sustainability and Scale
Lifespan Benefits of Early Child
Development Programs
Ensure adequate nutrition, esp. first 1000 days
School readiness (parenting & preschool
programs)
Academic success
Healthy psychological development
Avoid early pregnancy
Reduce violence & illegal behavior
Positive earning potential
Adult health & civic contribution
Strong & healthy children – 2nd gen
Break the Cycle of Poverty and Disparities
Promote Human Capital
One more thing -
I need opportunities to play and learn with a sensitive,
responsive caregiver. Remember, I am your future!
Thank You!
Clean, fed and nurtured?
WASH
Time, costs,
workload,
opportunities
Environmental
Enteropathy
Nematode
infection
Diarrhoeal
Diseases
Child development
Other
Diseases
Dinner: Bistro Bistro
1727 Connecticut Ave NW,
Washington, DC 20009