Elsevier

The Lancet

Volume 369, Issue 9557, 20–26 January 2007, Pages 229-242
The Lancet

Series
Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world

https://doi.org/10.1016/S0140-6736(07)60112-3Get rights and content

Summary

This paper is the third in the Child Development Series. The first paper showed that more than 200 million children under 5 years of age in developing countries do not reach their developmental potential. The second paper identified four well-documented risks: stunting, iodine deficiency, iron deficiency anaemia, and inadequate cognitive stimulation, plus four potential risks based on epidemiological evidence: maternal depression, violence exposure, environmental contamination, and malaria. This paper assesses strategies to promote child development and to prevent or ameliorate the loss of developmental potential. The most effective early child development programmes provide direct learning experiences to children and families, are targeted toward younger and disadvantaged children, are of longer duration, high quality, and high intensity, and are integrated with family support, health, nutrition, or educational systems and services. Despite convincing evidence, programme coverage is low. To achieve the Millennium Development Goals of reducing poverty and ensuring primary school completion for both girls and boys, governments and civil society should consider expanding high quality, cost-effective early child development programmes.

Introduction

This is the third paper in a series that addresses the lost developmental, educational, and economic potential of more than 200 million children under the age of 5 years in developing countries.1 The second paper identified risks with the strongest evidence base and highest prevalence as stunting, iodine and iron deficiencies, and inadequate cognitive and social-emotional stimulation.2 Less well-documented, but with consistent epidemiological evidence, are risks related to social conditions (maternal depression and violence), environmental factors (lead and arsenic), and some infectious diseases (malaria and HIV). Risk factors often co-occur and interfere with children's development, thereby contributing to a trajectory that includes poor health, lack of readiness for school, poor academic performance, inadequate preparation for economic opportunities, and perpetuation of the intergenerational cycle of poverty.

This paper examines the effectiveness of intervention programmes in developing countries. Based on the recommendations from earlier papers in this series,1, 2 we assess programmes that promote child development through preventing or ameliorating the effects of stunting, iodine deficiency, iron deficiency anaemia, and inadequate stimulation. We also identify examples of interventions to reduce the effects of social, environmental, and infectious risks. We include only evaluations that report cognitive or social-emotional outcomes.

Child development refers to the ordered emergence of interdependent skills of sensori-motor, cognitive-language, and social-emotional functioning (figure 1). Early child development programmes3 are designed to improve the survival, growth, and development of young children, prevent the occurrence of risks, and ameliorate the negative effects of risks. Most are directed toward disadvantaged children. Some programmes work directly with children through improved services such as growth monitoring, early child-care centres, or improved hygiene or health services; others work with parents to improve their parenting skills and resources, through home visits, group sessions, or communication for behaviour change.

Awareness of child development is increasing in developing countries. The health sector has advocated for early child development programmes for children with low birthweight,4 developmental delays,5 and from low-income disadvantaged environments.6, 7, 8 Child development information is often incorporated into growth monitoring charts. Government-supported preschool programmes for children are increasing; in the past 15 years, at least 13 developing countries have instituted compulsory preschool or pre-primary programmes.9 By 2005, the World Bank had financed loans to 52 developing countries for child development programmes, for a total of US$1680 million, at least 30 developing countries had policies on early child development,10 and UNICEF was assisting governments in supporting parenting programmes in 60 countries.10 Despite this interest, there have been few systematic evaluations of early child development programmes in developing countries.

Section snippets

Improving food intake and reducing stunting

Both efficacy trials and programme evaluations have shown that improving the diets of pregnant women, infants, and toddlers can prevent stunting11, 12 and result in better motor and mental development.2, 13, 14 Food supplementation during the first 2–3 years of life improves cognition at 3 years of age and beyond.13, 15 One trial showed an improvement in motor development with exclusive breastfeeding.16 The longest follow-up duration is from Guatemala, where supplementation before age 3 years

Social risks

There have been few evaluations of social protection interventions designed to mitigate the effects of social risks (eg, maternal depression, exposure to domestic and community violence, and stigma and loss due to HIV/AIDS) on children from developing countries. Women in developing countries have high rates of stress and depressive symptoms,86, 87 often associated with poverty, lack of support, and negative life events. Children of depressed mothers are at risk for poor development, in part

Future directions and crucial issues

In the final section we discuss priorities for improving the development of the 200 million children younger than 5 years at risk for cognitive and social-emotional deficits.

Conclusion

Effective interventions are available to reduce the developmental loss currently estimated to affect more than 200 million children under 5 years of age in developing countries, by promoting child development and preventing or ameliorating developmental loss. The most effective interventions are comprehensive programmes for younger and disadvantaged children and families that are of adequate duration, intensity, quality, and are integrated with health and nutrition services. Providing services

Search strategy

Databases searched were MEDLINE (PubMed), Embase, Psych Info, the Cochrane Review, the Educational Resources Information Center (ERIC), the World Health Organization, the World Bank and the International Bureau of Education for UNESCO (United Nations Educational, Scientific and Cultural Organization), SIGLE (grey literature from Europe), LILACS (Latin American and Caribbean Health Services), and UNICEF. The UNICEF and World Bank databases were searched and queries were sent to

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