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Child development in developing countries. S Grantham-McGregor Centre for Health and Development, Institute of Child Health, University College London.

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slide1

Child development in developing countries

S Grantham-McGregor

Centre for Health and Development, Institute of Child Health,

University College London

slide2

The Lancet series: The development of children <5 yrs in developing countries(Grantham-McGregor et al 2007, Walker et al 2007,P Engle et al 2007)

  • The size of the problem
  • The causes

International Child Development Steering Group:S Grantham-McGregor, P Engle, M Black, J Meeks Gardner, B Lozoff, T Wachs, S Walker,

Paper 1&2, Y B Cheung, S Cueto, P Glewwe, Richter, B Strupp, J Meeks Gardner, GA Wasserman, E Pollitt, JA Carter

overall aims of lancet series

Overall Aims of Lancet Series

To increase awareness of the problem of poor development in early childhood in low resource countries.

To make the promotion of optimal child development an international priority.

Bring together academics from many different disciplines from universities, UN agencies and NGOs to develop a consensus for action.

aims of paper

Aims of paper

Estimate the size of the problem

Identify the location of affected children

Estimate cost and consequences

Factors causing poor development

why focus on early childhood
Why focus on early childhood?
  • Brain development most rapid and vulnerable from

conception to 5 years

  • Insults and interventions can have lasting effects
  • Interventions are more cost effective than at other ages
  • Cognitive ability & behaviour on entry school progress
slide6

Domains of Child Development

Sensory-motor

Cognitive-language

Social-emotional

major problem with estimating numbers of affected children
Major problem with estimating numbers of affected children
  • Insufficient data on early cognitive ability for most developing countries to estimate prevalence
need to use risk factors as indicators of poor child development to assess prevalence
Need to use risk factors as indicators of poor child development to assess prevalence
  • 1. Stunting (<-2SD)
  • 2. Poverty<$1 per day (adjusted for purchasing power by country, World Bank 2005)
requirements of indicators
Requirements of indicators
  • Standardised measures across countries
  • Global data available
  • Relevant in most countries
  • Consistently related to poor child development and school achievement in developing countries ?
slide10

Stunting in children

> 28 studies

X-sectional associations

between stunting & poor cognition or school

achievement

longitudinal data essential
Longitudinal data essential

Jamaica Walker

South AfricanRichter, Norris

Phillipines Cebu study

Uganda dataFamily Life Study

Brazil Victora, Barros, Damiani, Lima, Gigante, Horta

Peru Berkman, Lescano

Guatemala Martorell

cognitive or schooling deficits associated with moderate stunting 3yrs in 7 longitudinal studies
Cognitive or schooling deficits associated with moderate stunting <3yrs in 7 longitudinal studies

SD scores

15yrs

7yrs

7yrs

18yrs

9yrs 17-18yrs

18-25yrs

Philippines S Africa Indonesia Brazil Peru Jamaica Guatemala

slide13

Conclusion

Reasonable to use stunting as an indicator of poor child development

slide14

Poverty <1 per day

>60 X-sectional studies showed associations with wealth and school achievement or cognition

slide15
Later cognitive deficits associated with being in the lowest wealth quintile <3yrs in 5 longitudinal studies (SD scores)

15yrs

7yrs

7yrs

18yrs

18-26yrs

Philippines Indonesia S Africa Brazil^ Guatemala*

^Grades attained *boys

slide16

Conclusion

Reasonable to use poverty as an indicator of poor child development

millions of children 5y not fulfilling their potential in development who 2006 unicef 2006
Millions of children < 5y not fulfilling their potential in development (WHO, 2006; UNICEF 2006)

219m (39% of children <5y)

156m

126m

Stunted +

Poverty not stunted

Stunted Poverty Disadvantaged

limitations
Limitations
  • Other risk factors not included
  • Cut off for poverty uncertain
  • Estimate for numbers of children based on poverty rates for total population

Underestimate

loss of yearly adult income
Loss of yearly adult income
  • Deficit in grades attained (Brazil)

2. Deficit in learning per grade (Phillipines, Jamaica)

3. Estimate total deficit (1+2)

4. Using estimate of 9% loss in income per grade

(53 countries Psacharopoulos 2004, Duflo 2001)

20 % loss of yearly adult income

conclusion
Conclusion

Loss of children’s potential is an enormous

problem affecting >200million

It has economic and social costs both to

individual and nations

selection criteria
Selection criteria
  • Modifiable by interventions or public policy
  • Affect large number of children less than 5 years in developing countries
  • Risks with little information from developing countries excluded
four main risks
Four main risks
  • Chronic undernutrition leading to stunting
  • Iodine deficiency
  • Iron deficiency anemia (IDA)
  • Inadequate cognitive stimulation
slide26

Deficits at 17 yrs in Jamaican children stunted before 2 yrs

IQ, vocabulary, cognition

school achievement /drop out

fine motor

depression, anxiety, attention deficit,

self esteem, hyperactive, oppositional

Walker et al 2005, 2006

mean corticosterone levels pre post stress in non handled handled and maternally separated rats
Mean Corticosterone Levels Pre & Post Stress in Non-handled, Handled and Maternally-separated Rats

(n= 8 per group)

µg/dl

Pre-

stress

Plotsky & Meaney 1993

Time (min)

intervention studies
Intervention studies
  • 15 of 16 intervention studies providing cognitive stimulation show benefits to development
  • Centre based or home based:

Effect size 0.5-1 SD

Lancet paper2

effects of visiting frequency in disadvantaged children

110

weekly

106

102

98

94

Pre-test

Post-test

Effects of visiting frequency in disadvantaged children

DQ

fortnightly

monthly

no visits

Powell & Grantham-McGregor, 1989

cognitive ability at 7 years by duration of center based intervention colombia
Cognitive ability at 7 years by duration of center based intervention; Colombia

Cognitive ability

0

1

2

3

4

Periods of intervention

McKay et al, 1979

interventions with stunted children
Interventions with stunted children

DQ

non-stunted

control

both Rxs

stimulated

supplemented

Grantham-McGregor et al, 1991

sustained benefits at 17 18 years from early childhood stimulation in stunted children
Sustained:Benefits at 17-18 Years From Early Childhood Stimulation in Stunted Children

P value

**

**

*

*

**

**

***

***

ns

ns

ns

ns

Standard scores

*p<.1; **p<.05, ***p<.01

Walker et al, 2005

sustained b enefits at 17 18 years from stimulation in early childhood in stunted children
Sustained: Benefits at 17-18 years from stimulation in early childhood in stunted children

P value

**

**

**

ns

**

ns

ns

*

Standard scores

*p<.1; **p<.05

Walker et al unpublished

slide36

Summary of stimulation studies

  • Consistent concurrent benefits to child’s DQ
  • Benefits greater in :
  • more intense, longer, include nutrition
  • Sustainable cognitive,education and mental health benefits at 17-18yrs
conclusion good evidence for 4 main risks
Conclusion: Good evidence for 4 main risks
  • Chronic undernutrition leading to stunting
  • Iodine deficiency
  • Iron deficiency
  • Inadequate cognitive stimulation
other risk factors
Other risk factors
  • Risk factors with consistent epidemiological evidence showing association with development
  • Lack of interventions with evaluation of effectiveness
other risks identified
Other risks identified

Small for gestational age

Malaria

Maternal depression

Exposure to violence

Exposure to environmental toxins

multiple risks in early childhood and achievement scores in adolescence
Multiple risks in early childhood and achievement scores in adolescence

Risk factors

Gorman and Pollitt, 1996

mean developmental quotients on griffiths test
Mean Developmental Quotients on Griffiths Test

DQ

Urban middle class n=78

Urban poor

n=268

Age months

(Walker et al)

slide42

Maternal stress/

depression

Low education

Poor care and

home stimulation

Poor school

achievement

Poor hygiene,

feeding practices,

care-seeking

Poverty

Poor cognitive,

socio-emotional

development

Poor sanitation,

Food insecurity

Stunting & wasting, iodine & iron deficiency, diarrhoea,infections

slide43

national

economy

countries with highest of children 5y who are stunted in latin america the caribbean unicef 2006
Countries with highest % of children < 5y who are stunted in Latin America & the Caribbean (UNICEF 2006)

%

types of evidence
Types of evidence
  • Randomised trials and intervention studies
  • Prospective cohort studies
  • Associational studies (with control for confounders)
vocabulary scores by ses quartiles in 36 to 72 month old children equador paxson and shady 2005
Vocabulary scores by SES quartiles in 36 to 72 month old children EquadorPaxson and Shady2005

age in months

why health services
Why health services?
  • Only service accessing children in first 3 years
  • Already has an infrastructure
  • Development an integral part of health
  • Poor health & nutrition poor development
  • Mothers enjoy and can facilitate other activities
  • We cannot wait for new services
why psychosocial stimulation interventions
Why psychosocial stimulation interventions?
  • Malnourished children do not catch up with nutrition alone
  • Stimulation changes brain function in animals
  • Adoption studies show vast improvement
  • In USA disadvantaged children have shown sustained benefits
iq scores of stunted and non stunted jamaican children from age 9 24 mo to 18 y
IQ scores of stunted and non-stunted Jamaican children from age 9-24 mo to 18 y

0.8

0.6

Non-stunted

0.4

0.2

SD score

0

-0.2

Stunted.

-0.4

-0.6

Griffiths on

Griffiths

(33-48 mo)

Stanford-

WISC-R

(11-12 y)

WAIS

(17-18 y)

Enrollment

(9-24 mo)

Binet

(7-8 y)

Walker et al 2005

slide50

7 longitudinal studies of stunting <3yrs &

later function

Country Follow-up age Outcome

Indonesia 7 cognitive test

S Africa 7 cognitive test

Peru 9 IQ

Philippines 15 schooling

Jamaica 17-18 schooling, IQ

Brazil 18 attained grades

Guatemala 18-26 schooling, IQ