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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

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wash and child growth development

Clean, Fed & Nurtured: Joining forces to promote child growth and development

WASH andChild 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
WASH basics
  • Water
    • quantity and quality
  • Sanitation
    • Faecal waste disposal
  • Hygiene
    • Hand, Food, Environment
slide3

0.85m deaths a year

2-3.5bn episodes

Source: Liu et al, Lancet 2012

slide4

Fluids

Fields

New Host

Faeces

Foods

Flies

Fingers

slide5

Fluids

Fields

New Host

Faeces

Foods

Flies

Fingers

slide6

Fluids

Fields

New Host

Faeces

Foods

Flies

Fingers

slide7

Fluids

Fields

New Host

Faeces

Foods

Flies

Fingers

slide8

Fluids

Fields

New Host

Faeces

Foods

Flies

Fingers

slide9

Fluids

Fields

New Host

Faeces

Foods

Flies

Fingers

slide10

Fluids

Fields

New Host

Faeces

Foods

Flies

Fingers

slide12

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
WASH and nutrition

Poor WASH

Faecal-oral exposure

Nematode infection

Diarrhoeal Diseases

Environmental

Enteropathy

Poor nutritional status

cochrane public health group
Cochrane Public Health Group
  • Includes
    • RCTs
    • non-randomised controlled studies
    • interrupted time series studies
  • WASH included as one intervention
review protocol
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
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
included studies
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
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
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
interpretation
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
Concerns

Publication bias

Quality of studies

Links in the pathway?

conclusions of cochrane review
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 nutrition1
WASH and nutrition

Poor WASH

Faecal-oral exposure

Nematode infection

Diarrhoeal Diseases

Environmental

Enteropathy

Poor nutritional status

diarrhoea and stunting
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 nutrition2
WASH and nutrition

Poor WASH

Faecal-oral exposure

Time, costs, workload

Nematode infection

Diarrhoeal Diseases

Environmental

Enteropathy

Other Diseases

Poor nutrition

wash and ecd
WASH and ECD

Poor WASH

Faecal-oral exposure

Time, costs, workload

Nematode infection

Diarrhoeal Diseases

Environmental

Enteropathy

Other Diseases

Poor ECD

diarrhoea giardia and ecd
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
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
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?

nutrition and child growth development

Clean, Fed & Nurtured: Joining forces to promote child growth and development

NUTRITION andChild Growth & Development

Washington, DC | May 2-3, 2013

Kay Dewey

UC-Davis and Alive & Thrive

nutrition basics
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
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
Outline

Impact of nutrition interventions on linear growth (child’s height)

Impact of nutrition on child development

The need for combined interventions

slide42
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

prenatal nutrition interventions
Prenatal nutrition interventions
  • 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 interventions1
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 interventions2
Prenatal nutrition interventions

C. Fortified foods for pregnant women

Lipid-based nutrient supplement (LNS)

(Huybregtset al. Am J ClinNutr2009), 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
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
Complementary feeding 6-24 mo

6-24 mo: Complementary feeding

Guiding principles for complementary feeding (2003; 2005)

  • Several strategies:
    • Educational approaches
    • Increasing energy density of complementary foods
    • Provision of complementary food
    • Fortification
  • Potential for major impact on stunting but evidence is mixed

47

complementary feeding 1
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 animal-source 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
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
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
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
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
slide53

Impact of nutrition on

child development

slide54
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
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 brief1
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 caregiver-child interaction.

slide57

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
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
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 pre and postnatal nutrition interventions
Little evidence on impact of combined pre- and 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
Trials with combined pre- and postnatal nutrition are underway
  • iLiNSProject: 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
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
early child development

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
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 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
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
Child Development: Multiple Contributing Factors

Nutrition

Health

School and Community Services

Nutrition is necessary for child development, but not sufficient!

Learning

Opportunities

Protection from Stress/

Harm

Family Support

Sensitive/

Responsive

Caregiving

Social

Protection

threats to early development
Threats to Early Development

Shonkoff , Pediatrics, 2012

  • Poverty and Undernutrition
  • Toxic stress
    • Children can handle, even benefit, from mild stress
    • Toxic stress
      • Institutionalization, maltreatment, neglect, trauma, undernutrition
      • Lack of caregiver responsivity
how toxic stress undermines child development
How Toxic Stress Undermines Child Development

Johnson et al., Pediatrics, 2013; 131:319-327

  • 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
parent nurturance responsivity
Parent Nurturance/Responsivity

Buffering effects of nurturant parenting

Johnson et al., Pediatrics, 2013; 131:319-327

hippocampal volume by preschool depression severity maternal support
Hippocampalvolume 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

2007 2011 lancet series on child development
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
Target of Interventions

Kramer et al., 2008; 2007 & 2011 Lancet series on Child Development

  • Prenatal
    • Prevent Toxic stress/LBW/Prematurity
  • Infancy
    • Breastfeeding, complementary feeding
    • Responsive Parenting
    • Opportunities for early learning
    • Routines to promote regulation
    • Family support
early child development intervention
Early Child Development Intervention

Black & Aboud, 2012

  • 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
slide80

PROMOTES HEALTHY EATING & GROWTH PATTERNS

Ummm, maybe she is telling me she wants to feed herself.

RESPONSIVE FEEDING BEHAVIORS

Caregiver

offers a bite

of food

Caregiver

offers another

bite

Child

opens

mouth &

accepts

Child

looks away,

mouth

shut

…………………...Time…………

slide81

PROMOTES HEALTHY EATING & GROWTH PATTERNS

RESPONSIVE FEEDING BEHAVIORS

Caregiver

offers a bite

of food

Caregiver

offers another

bite

Caregiver

waits, smiles,

finger food

Child

opens

mouth &

accepts

Child

looks away,

mouth

shut

Child

picks up food

& eats

…………………...Time…………

slide82

HINDERS HEALTHY EATING & GROWTH PATTERNS

Oh no, I am late. She has to finish eating.

NON-RESPONSIVE FEEDING BEHAVIORS

Caregiver

offers a bite

of food

Caregiver

offers another

bite

Child

opens

mouth &

accepts

Child

looks away,

mouth

shut

…………………...Time…………

slide83

HINDERS HEALTHY EATING & GROWTH PATTERNS

NON-RESPONSIVE FEEDING BEHAVIORS

Caregiver

holds child &

force feeds

Caregiver

offers a bite

of food

Caregiver

offers another

bite

Child

opens

mouth &

accepts

Child

looks away,

mouth

shut

Child

Cries & spits

out food

…………………...Time…………

responsive unresponsive feeding
Responsive/Unresponsive Feeding

UNRESPONSIVE

  • Controlling, indulgent, or uninvolved
  • Ignores/overrides infant cues
  • Associated with
    • Difficult temperament
    • Maternal mental health symptoms
    • Poor growth (under or overweight)

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
parenting interventions 0 3 yrs
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
Preschool interventions (3-5 yrs)

Lancet series on child development, 2007, 2011

  • Preschools improve children's cognitive & social-emotional development: school readiness
  • Impact is greatest with high quality programs
    • Teacher-student ratio
    • Developmental curriculum
    • Student exploration
    • Teacher responsivity
characteristics of successful programs
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 & evidence-based practices (curriculum, materials)

Systematic in-service training, supervision, monitoring, and evaluation

Lancet series on child development, 2007, 2011

how do integrated programs work
How do Integrated Programs Work?

Intervention Child Development

Social-

Emotional

Cognitive/Language

Sensori-Motor

Direct effect of child development intervention

Lancet series on child development, 2007, 2011

Child Devel

how do integrated programs work1
How do Integrated Programs Work?

Intervention Child Development

Social-Emotional

Cognitive/Language

Sensori-Motor

Nutrition

Direct effect of nutrition intervention

how do integrated programs work2
How do Integrated Programs Work?

Intervention Child Development

Social-Emotional

Cognitive/Language

Sensori-Motor

Nutrition

Additive effect of child development & nutrition intervention

Child Devel

dq iq stunted and non stunted children in jamaica effects of ecd intervention
DQ/IQ Stunted and Non-stunted Children in Jamaica: Effects of ECD Intervention

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 work3
How do Integrated Programs Work?

Intervention Child Development

Social-Emotional

Cognitive/Language

Sensori-Motor

Nutrition

Synergistic effect: Impact of 2 interventions greater than their sum. One intervention enhances the impact of the other intervention.

Tested with an interaction term.

Child Devel

example of synergistic intervention
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
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
Integrated InterventionsQuestions

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
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

slide99

One more thing -

  • I need opportunities to play and learn with a sensitive, responsive caregiver. Remember, I am your future!
clean fed and nurtured
Clean, fed and nurtured?

WASH

Time, costs, workload, opportunities

Nematode infection

Diarrhoeal Diseases

Environmental

Enteropathy

Other Diseases

Child development

dinner bistro bistro
Dinner: Bistro Bistro

1727 Connecticut Ave NW,

Washington, DC 20009