Lancet Publishes Groundbreaking Series on Early Childhood Development

“There can be no equality of opportunity without... appropriate stimulation, nurturing, and nutrition for infants and young children. Conditions of poverty, toxic stress and conflict will have produced such damage that they may never be able to make the best of any future opportunities. If your brain won’t let you learn and adapt in a fast changing world, you won’t prosper and, neither will society.”
- World Bank Group President Jim Yong Kim, Oct 1, 2015

Every day we see the global images of war, of poverty, of earthquakes and typhoons. And no image is more wrenching than that of children. They become symbols of vulnerability, burned in our consciences: exhausted toddler refugees crowded into lifeboats; desperate children in Haiti clamoring for post-hurricane provisions; a bloodied Syrian boy sitting in an ambulance, in shock, after his home is bombed.

What will happen to that boy, and to the millions of children who have endured similar nightmares? Not just violence, but hunger, fear, neglect, abuse, and chronic deprivation of basic needs.

A new series in the Lancet, Advancing Early Childhood Development: from Science to Scale, makes some troubling predictions. Drawing on neuroscience, epigenetics, public health, and economics, the authors – with support from UNICEF, the World Bank, and the World Health Organization – have attached not only a biological and moral cost to this epidemic of adversity, but also a monetary one.

In middle and low-income countries, almost 250 million children – 43 percent of children under five – will fail to meet their developmental potential because of extreme poverty and deprivation. The cognitive deficits, physical and mental illness, and lack of education that come from such early and extreme stress will translate into lower salaries, less job satisfaction, less independence, and a markedly less-satisfying life.

“We suggest that this gap in human potential is partly due to two reasons,” the Lancet authors write. “The failure to apply emerging scientific knowledge on nurturing care to shape young children’s development; and the failure to take action at scale, using a multi-sector approach across key stages in the early life course.”

This is not just a cumulation of individual losses, the series explains. It is a massive societal loss, resulting in a hard, tangible liability to entire countries. But if tragedy alone cannot spur world leaders to act to protect children, then perhaps financial realities will.

According to the Lancet series, the children damaged by early adversity stand to lose out on 26 percent of the income they would otherwise earn. Countries that do not invest in preventing this "stunting" effect at the outset can expect to spend up to twice their entire health budgets on the after-effects. And intervening before it's too late could cost as little as fifty cents per child.

“The enormous cost of not doing anything, and the affordability of actually doing something that could be effective, is really a very strong economic case,” said co-author Linda Richter, professor at the University of Witwatersrand in Johannesburg, South Africa, in a podcast released with the series. “Trickle down economic growth is insufficient. We also need bottom up human development growth.”

The three-paper Lancet series starts by surveying new science on child brain development after adversity, which has grown considerably since the previous two Lancet publications on early childhood development in 2007 and 2011. One clear conclusion is: there's no time to lose.

“It's much easier to catch up when interventions are early,” said Richter. “We also know that it's very seldom that children who are disadvantaged get the kind of interventions they would need to catch up later.”

Among the scientific highlights:

• Children in the first 1000 days of life – from conception to two or three years old –  are most vulnerable to adversity and most responsive to intervention.
• Through the lens of epigenetics – which looks at how gene expression is affected by environmental factors even if DNA remains the same –adversity in one generation can lead to developmental shortcomings in later generations.
• Poverty is associated with developmental delays in the first year of life, and those delays expand over a lifetime.
• Longitudinal studies, such as following orphans in Romania through institutionalization and foster care, show the longterm impact of psychological deprivation as well as the potential for reversal.
• Parenting that focuses heavily on nurturing can help reverse the damage caused by adversity.

The Lancet series also evaluates what's already being done through existing intervention programs. Sixty-eight countries have early childhood policies in place – that's up from seven in previous Lancet series – including Uganda, Bangladesh, India, and Brazil. And several individual programs provide evidence that investing in child development works, including Sure Start in the UK, Early Head Start in the U.S., and Crece Contigo in Chile.

More countries today have increased enrollment in child care for children ages three and under – notably in Latin America – though the quality of programs vary widely, with the poorest risking harm rather than progress. And while many campaigns for universal preschool have been successful, there's still a huge gap between rich and poor countries. (Nineteen percent in low income countries as compared to 86 percent in higher income countries, with inequality rife even within those countries.)

The best results, the authors found, combine what's known as known as "nurturing" care with basic health, nutrition, and cognitive programs.

Highlights from program evaluations include:

• Prenatal care is paramount, from iodine supplements to deworming and proper nutrition. Giving cash to pregnant women so they can get prenatal care has led to significant positive results.
• When it comes to mitigating the effects of adversity on the young brain, some of the simplest and least expensive interventions are among the most effective – like reading aloud at home, telling stories, and facilitating play.
• Psychosocial interventions by community health workers for brand new moms lead to stronger mother-baby attachment and infant cognitive function.
• Programs that focus on teaching parental nurturing, including breastfeeding techniques, show particular promise.

In a final section, the Lancet series leans on policy makers and political leaders to prioritize early childhood development. Understanding which interventions work is a first step. Countries then need to create conditions that allow those programs to flourish and reach the right populations, supporting initiatives such as paid parental leave, breastfeeding breaks at work, paid sick leave, a minimum wage to lift people out of poverty, and access to free preschool.

Leaders must also help coordinate the myriad of disconnected programs that exist in separate social and economic silos. To get those programs to the families who need them, the authors suggest launching programs where the most vulnerable populations already interact with institutions or community leaders, such as clinics and schools. Community health programs offer a particular opportunity to reach pregnant women and very young children, at a time when interventions can do the most good.

Most urgently, the authors say, advocates need to focus on developing the political will to invest in early childhood programs. They suggest appointing a UN Special Advisor for Early Childhood Development as a way to push the issue high up on political agendas. Individual countries must also scale up pilot programs to reach entire populations, a task the authors hope will be easier when countries are armed with evidence on the devastating costs of not doing enough.

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Audio Interview with Lancet Series Co-Author, Gary Darmstadt

Gary Darmstadt is a pediatrician who has spent his career studying global maternal and newborn health and newborn survival and, more recently, how to optimize the development of surviving children. Darmstadt is Associate Dean for Maternal and Child Health at Stanford University School of Medicine. He was on the steering committee that led the planning, research, and writing of the Lancet series on early child development.

Darmstadt spoke with Karen Brown about the series. He starts by explaining how the series authors defined the “lost potential” that is facing 250 million children who live in extreme poverty, war, or other states of deprivation.