Comment

Putting science into practice for early child development

The debate between nature and nurture as determinants violent conflicts and other catastrophes. Toxic stress
of early child development is over. Today, we understand increases the production of cortisol, a hormone that can
that the two are inextricably linked. The degree of their disrupt the healthy development of the brain, affecting
interdependence—and the impact of this interplay health, learning, and behaviour. Toxic stress also
on the developing brains of children—is even greater undermines the ability of the body to absorb nutrients,
UNICEF/NYHQ2011-0721/Asselin

than we previously imagined.1 This knowledge has so potentially exacerbating malnutrition.5

tremendous implications for how we design and deliver We are just beginning to understand how environ-
early child development interventions. mental factors—including the quality of parenting—
During the past 24 years, the united efforts and shared might modify the expression of genes, and possibly
goals of the global community have achieved substantial affect not just one, but multiple, generations.6,7 This
Published Online progress in child survival, and child mortality worldwide growing area of inquiry is beginning to change the way
September 20, 2014
http://dx.doi.org/10.1016/
has declined by 49%.2 We can build on those gains by we think about development in early childhood and
S0140-6736(14)61680-9 focusing new effort and attention not only on saving early childhood development interventions. As separate
children’s lives, but also on supporting the healthy fields of study begin to come together to translate
development of their brains. This is especially important scientific evidence into practical action, some key
for the millions of children growing up in the most recommendations are emerging.
disadvantaged and vulnerable communities and countries, First, early intervention is essential. Neuroplasticity
who already face multiple adversities and whose societies begins to decline after early childhood. It becomes
also suffer the consequences of those deprivations. progressively harder to offset the effects of early
We already know that the brain develops most rapidly childhood deprivation on the brain. Interventions are
in the first few years of a child’s life. During these most effective during the period of most dynamic
critical years, neuroplasticity is at a peak—neurons growth, and what happens in these early years affects a
form new connections at the astounding rate of up child for life.
to 1000 per second.3 These synaptic connections are Second, to be most effective, interventions must be
the foundation of a child’s physical and mental health, intersectoral, going beyond education to encompass
affecting everything from longevity to the lifelong health, nutrition, and protection. The healthy develop-
capacity to learn, from the ability to adapt to change to ment of a child’s brain depends on multiple positive
the capacity for resilience. experiences. Nutrition feeds the brain; stimulation
New lines of research are expanding our understanding sparks the mind; love and protection buffer the
of the part environment plays in the formation of these negative impact of stress and adversity. And distinct
neural connections. If children fail to get what they interventions are mutually supportive, achieving the
need—enough nutrition, nurturing, stimulation, and strongest results when delivered together. One example
a sense of security—during the most critical years of is Care for Child Development,8 an intervention jointly
early childhood, the impact on their lives and futures is developed by WHO and UNICEF that instructs mothers
enormous. For example, inadequate nutrition in the early and caregivers to stimulate language and learning in
years of childhood can result in stunting, which can cause young children using everyday objects and activities.
diminished physical and cognitive development that This intervention is designed to be delivered with
undermine a child’s ability to learn and earn later in life. instruction on the importance of improving nutrition
Similarly, inadequate stimulation during the same critical for young children. Better nutrition, in turn, supports
period of earliest childhood can reduce learning capacity a child’s ability to benefit from cognitive stimulation.
and ability to form social and emotional attachments.4 By increasing the quantity and quality of caregiving,
The impact of such deprivations can intensify in these interventions also strengthen affectionate
situations that produce toxic stress in children, including bonds between children and parents. In doing so, this
chronic deprivation and prolonged hunger, domestic approach effectively reinforces a sense of responsibility
violence and abuse, and the effects of living through to continue the interventions: a virtuous cycle.

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 Comment

Intersectoral interventions in early childhood are workers to guide mothers in the importance of early
also important because of the complex interactions of stimulation. The cost of delivering these interventions
toxic stress, nutrition, and brain development. Studies is exceeded by the short-term and long-term benefits:
show that nutritional supplements alone will not fully children who benefited from these interventions
alleviate the effects of malnutrition in children who earned between 20% and 40% more in adulthood than
also experience high levels of toxic stress.9 Similarly, those who did not.11
failing to provide adequate nutrition undermines the As the Millennium Development Goal period
development of neural connections: a vicious cycle. comes to a close and the post-2015 development
This knowledge has special significance in the context agenda takes shape, the global community has
of humanitarian emergencies, and underlines the need an opportunity to assess its progress in reducing
to minimise the negative impact of toxic stress and poverty, and in expanding growth, prosperity, and
inadequate nutrition in the lives of the most vulnerable sustainable development. Even more, it has the
of all children. responsibility to address the barriers that remain. We
Third, designing interventions to optimise brain have an opportunity now to do just that, by translating
development must also take into account the entire scientific knowledge into practical solutions to change
lifecycle, beginning with maternal health and prenatal the lives of millions of children.
care. This means investing more in interventions to
support mothers before conception, during pregnancy Anthony Lake, *Margaret Chan
and childbirth, and beyond. Similarly, we must also UNICEF, New York, NY, USA (AL); and WHO, 1211 Geneva 27,
Switzerland (MC)
focus attention and resources on adolescence, the
[email protected]
period during which the developing brain consolidates
AL is Executive Director of UNICEF. MC is Director-General of the World Health
the neural connections formed in the early years. We Organization.
now understand that such interventions could help © 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights
offset, although not fully ameliorate, the effects of reserved.
1 Britto PR, Engle PL, Super CS, eds. Handbook of early childhood
earlier deprivation. development research and its impact on global policy. New York: Oxford
Today, 200 million children younger than 5 years are University Press, 2013.
2 United Nations Inter-agency Group for Child Mortality Estimation. Levels
not achieving their developmental potential.10 Most and trends in child mortality. Report 2014. New York: United Nations
of these children are growing up in the poorest Children’s Fund, 2014.
3 Shonkoff JP, Richter L. The powerful reach of early childhood development:
households of their respective societies. They are the a science-based foundation for sound investment. In: Britto PR, Engle PL,
children living in remote rural communities and urban Super CS, eds. Handbook of early childhood development research and its
impact on global policy. New York: Oxford University Press, 2013: 1–23.
slums; children living through emergencies and chronic 4 De Haan M, Gunnar MR, eds. Handbook of developmental social
neuroscience. New York: Guilford Press, 2009.
conflicts; children from minorities; and children with 5 National Scientific Council on the Developing Child. Excessive stress
disabilities. This loss of potential for these children is a disrupts the architecture of the developing brain: working paper 3. Updated
edition. Cambridge, MA: National Scientific Council on the Developing
personal tragedy; but more broadly, it helps perpetuate Child, Center on the Developing Child at Harvard University, 2014.
cycles of poverty and inequality in their societies and http://developingchild.harvard.edu/resources/reports_and_working_
papers/working_papers/wp3/ (accessed Sept 16, 2014).
undermines stability and prosperity. But investing in 6 Meaney M. Epigenetics and the biological definition of gene x environment
interactions. Child Dev 2010; 81: 41–79.
early interventions timed to take advantage of crucial
7 Moisiadis VG, Matthews SG. Glucocorticoids and fetal programming part 2:
phases of brain development can improve the lives of mechanisms. Nat Rev Endocrinol 2014; 10: 403–11.
8 WHO, UNICEF. Care for child development: improving the care of young
the most disadvantaged and vulnerable children and children. Geneva: World Health Organization, 2012.
their societies. 9 Wachs TD, Georgieff M, Cusick S, McEwen BS. Issues in the timing of
integrated early interventions: contributions from nutrition, neuroscience,
The long-term benefits of doing so are potentially and psychological research. Ann N Y Acad Sci 2014; 1308: 89–106.
great. Studies of children in Guatemala and 10 Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B;
International Child Development Steering Group. Developmental potential
Jamaica who participated in learning and nutrition in the first 5 years for children in developing countries. Lancet 2007;
programmes in their first 2–3 years of life showed 369: 60–70.
11 Gertler P, Heckman J, Pinto R, et al. Labor market returns to an early
dramatic differences in earning capacity later in life. childhood stimulation intervention in Jamaica. Science 2014;
344: 998–1001.
The interventions included a protein supplement
for infants, and home visits by community health

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