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An Integrated Scientic Framework for Child Survival

and Early Childhood Development


AUTHORS: Jack P. Shonkoff, MD,a Linda Richter, PhD,b
abstract Jacques van der Gaag, PhD,c and Zulqar A. Bhutta, MB,
BS, PhDd
Building a strong foundation for healthy development in the early years aCenter on the Developing Child at Harvard University
of life is a prerequisite for individual well-being, economic productivity, Cambridge, Massachusetts; bHuman Sciences Research Council
and harmonious societies around the world. Growing scientic evi- and the University of the Witwatersrand, South Africa;
cCenter for Universal Education, Brookings Institution, and the
dence also demonstrates that social and physical environments that
Amsterdam Institute for International Development, University of
threaten human development (because of scarcity, stress, or instabil- Amsterdam, The Netherlands and dDivision of Women and Child
ity) can lead to short-term physiologic and psychological adjustments Health, Aga Khan University, Karachi, Pakistan
that are necessary for immediate survival and adaptation, but which KEY WORDS
may come at a signicant cost to long-term outcomes in learning, be- child, child development, child survival, early childhood
havior, health, and longevity. Generally speaking, ministries of health development, global health, health disparities, poverty, risk
factors, social policy
prioritize child survival and physical well-being, ministries of education
ABBREVIATIONS
focus on schooling, ministries of nance promote economic develop- ECDearly childhood development
ment, and ministries of welfare address breakdowns across multiple EFAEducation for All
domains of function. Advances in the biological and social sciences HDIHuman Development Index
MDGMillennium Development Goals
offer a unifying framework for generating signicant societal benets
UNICEFUnited Nations Childrens Fund
by catalyzing greater synergy across these policy sectors. This synergy WHOWorld Health Organization
could inform more effective and efcient investments both to increase As lead author, Dr Shonkoff assumed primary responsibility for
the survival of children born under adverse circumstances and to conceptualizing the article, assigning the drafting of individual
improve life outcomes for those who live beyond the early childhood content sections by each of the co-authors, integrating all of
the articles sections, and producing a unied manuscript.
period yet face high risks for diminished life prospects. Pediatrics Drs Shonkoff and Richter originated the idea for the article, and
2012;129:e460e472 Dr Richter wrote a preliminary draft that Dr Shonkoff built out
considerably. Dr Richter contributed to all additions and
revisions of the paper. Dr Van der Gaag conceptualized and
wrote the section on human capital formation, and Dr Bhutta
created and produced the table, in addition to providing content
renement throughout the text.
www.pediatrics.org/cgi/doi/10.1542/peds.2011-0366
doi:10.1542/peds.2011-0366
Accepted for publication Sep 28, 2011
Address correspondence to Jack P. Shonkoff, MD, Center on the
Developing Child at Harvard University, Harvard University, 50
Church Street, Cambridge, MA 02138. E-mail:
jack_shonkoff@harvard.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated that they
have no nancial relationships relevant to this article to
disclose.

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Building a strong foundation for healthy system, and other body organs, as well undernutrition in the preschool years
development during the early years as behavioral adaptations that have accounted for a loss of more than two
of life is an important prerequisite for lifelong impacts on learning, behavior, grades in school and .30% in later
lifelong well-being, successful commu- and health.4 Under conditions of ex- adult income.14 Poverty is also associ-
nities, economic productivity, and har- treme disadvantage, short-term physi- ated with higher levels of exposure to
monious civil societies.1,2 Stated simply, ologic and psychological adjustments stressful conditions linked to violence,
a promising future belongs to those that are necessary for immediate sur- poor infrastructure, and lack of serv-
nations that invest wisely in their youn- vival may come at signicant cost to ices.15,16 The longer poor children are
gest citizens. Increasing evidence indi- lifelong health and development. In- exposed to these destabilizing circum-
cates that the lifelong burden of early deed, there is extensive evidence that stances, the greater the risk that their
disadvantages can be difcult to re- the long-term consequences of depri- stress response systems become dys-
verse, whereas a good start helps vation, neglect, or social disruption can regulated, which leads to increased sus-
children develop capacities to cope suc- create shocks and ripples that affect ceptibility to illness, disability, impaired
cessfully and contribute to the socio- generations, not only individuals, and learning, and social maladjustment in
economic development of the society have signicant impacts that extend both the short and long term.1720
in which they live. Thus, as progress is far beyond national boundaries.5 The failure to address conditions that
made in reducing child mortality, par- limit the life prospects of young chil-
ticularly in the poorest countries that CONFRONTING THE HUMAN AND dren seriously undermines the social
carry the greatest burden of unfullled SOCIETAL TOLL OF POVERTY and economic development sought by
human potential, improving the life all nations.2123 Setting priorities for
Severe economic hardship and social
prospects of those who survive pres- mitigating the adverse impacts of pov-
adversity impose a cumulative burden
ents an equally compelling priority.3 erty, discrimination, and/or violence on
of risk on hundreds of millions of chil-
To this end, new knowledge in the children, however, is not a simple task.
dren around the world, a burden that
biological and social sciences can in- The imperative of reducing prevent-
undermines multiple dimensions of
form innovative strategies to address able deaths is fundamental, and the im-
their lives, including resources, safety,
threats to child survival and well-being, plementation of effective interventions
care, and opportunities. Growing up in
and improve adult outcomes, as well, within existing health care systems
impoverished or unsafe conditions is
in ways that did not exist as recently remains a challenge.2434 Equally im-
associated with signicant threats to
as a decade ago. portant, however, is the realization
long-term physical and mental health,
that the campaign to save lives is in-
Advances in the life sciences have cognitive development, educational
complete if the future prospects of
deepened our understanding of the achievement, emotional well-being, and
those who survive are constrained by
importance of dynamic interactions social adjustment, and these impacts
continuing adversity, particularly in
among environmental inuences (in- are particularly potent in early child-
the poorest countries. Thus, the time
cluding exposure to toxic chemicals), hood.610 Whereas poverty is measured
has come to mobilize science to both
social experiences (including the de- primarily in terms of material assets
increase child survival and promote
bilitating effects of poverty, population and purchasing power, associated so-
early childhood development.
displacement, unstable relationships, cial and psychological dimensions such
and exposure to violence), nutrition (in- as social exclusion, lack of empower-
cluding the consequences of both in- ment, and a sense of hopelessness THE EARLY CHILDHOOD ROOTS OF
adequate and excessive food intake), also undermine family dynamics, child- HUMAN CAPITAL
and genetic predisposition (including rearing practices, and human devel- In 1990, the United Nations Development
the extent to which experiences can opment.11,12 Program adopted the Human Develop-
inuence gene expression) in affecting The undernutrition linked to poverty is ment Index (HDI), which incorporates
both individual and population well- estimated to contribute to 35% of all a rough assessment of health and ed-
being. New discoveries in molecular child deaths due to measles, malaria, ucation along with income, as an alter-
biology and epigenetics are explain- pneumonia, and diarrhea, as well as to native to the Gross Domestic Product
ing how early adversity, as a result of stunted growth for .200 million chil- per capita as a measure of a countrys
scarcity, stress, or instability, can lead dren worldwide.13 A recent analysis of overall well-being.34 Ten years later, the
to physiologic disruptions in the de- longitudinal data from low- and middle- international community adopted eight
veloping brain, the cardiovascular income nations found that poverty and Millennium Development Goals (MDGs),

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several of which address child-related prosperity.39,40 Recently, some econo- to reduce poverty and its correlates
aspects of health and education. This mists have looked beyond cognition (eg, malnutrition, disease, illiteracy)
perspective was reinforced further in alone and emphasized the extent to versus investments to stimulate eco-
the recent report of the Commission which emotional and social capacities nomic growth do not exist (in the long
on the Measurement of Economic Per- facilitate cognitive development41 and run) for investments in young children,
formance and Social Progress, which ultimate labor market productivity.42,43 where the net result is synergy, not
stated that the time is ripe for our These analysts have also noted that competition.
measurement system to shift emphasis competencies achieved at one stage The economic literature on human cap-
from measuring economic production increase the productivity of human ital development and prosperity has
to measuring peoples well-beingin capital investments at a later stage, progressed from the static life cycle
a context of sustainability.35 thus leading to dynamic multiplier models of the past, which focused
The movement toward measures of effects over time and a strong case for largely on formal education and labor
social and economic development that early intervention.44 market outcomes, to current dynamic
include dimensions of human well- Beyond the importance of attaining models that recognize the importance
being (such as nutrition, health, cog- skills, health status (including nutri- of the timing of investments, the rela-
nitive skills, and social competence), tion) is also highly correlated with tions among cognition, executive func-
rather than metrics that focus largely economic outcomes. An estimated 30% tion skills (ie, working memory, cognitive
on per capita income, underscores the of the growth in per capita income that exibility, and inhibitory control), and
argument for prioritized investment in occurred in Britain between 1790 and social competence, as well as interac-
the early childhood period, when the 1980 (a period that included the In- tions among multiple dimensions of
trajectories of these life outcomes are dustrial Revolution) has been explained human capital such as nutrition, health,
strongly inuenced by early experi- by the improved gross nutrition of the and school achievement.56,57 These con-
ences. Indeed, no country that has labor force.45 The correlation between temporary models also reect greater
failed to invest in its young children income and health indicators other understanding of the intergenerational
has experienced rapid development, than nutrition is also strong, yet the nature of human capital formation, par-
as measured by the HDI or the so-called causal direction has been harder to ticularly in terms of the links among
capability approach.36 Furthermore, determine. That said, substantial prog- maternal educational attainment, the
although some countries (eg, Brazil, ress has been made in establishing social status of women, and the healthy
China, and India) have achieved rela- the impact of health on wages and development of children.58,59 Building
tively rapid economic growth in recent productivity, especially in low-income on these conceptual shifts in econom-
years without substantial investment settings.46 Moreover, there is consid- ics, advances in neuroscience, genom-
in early childhood programs, their rising erable evidence documenting the re- ics, and developmental psychology are
wealth has been accompanied by sig- lation between early health status shedding new light on the underlying
nicant increases in income inequality, (including birth weight and growth causal mechanisms that link early life
with large segments of the population during the rst few years) and later experiences to adult human capital,
still lacking access to adequate health health outcomes in adulthood, as well thereby presenting an extraordinary
care, education, and vital social services. as with educational achievement, family opportunity to reframe policy discourse
Traditional human capital theory income, household wealth, individual in development economics.60,61
employs a life cycle model that links earnings, and labor supply.4751 In 2002, the General Assembly of the
investment in human capacity, such as Both the HDI and the MDGs recognize United Nations endorsed a new agenda
education, to increased productivity in the importance of health, nutrition, and entitled A World Fit for Children, which
the labor market, which, in turn, leads education as necessary components of included an expanded commitment to
to higher wages and aggregate eco- well-being that many view as a matter early childhood policies to enhance
nomic growth.37,38 Generally speaking, of basic human rights.52,53 It is also be- physical, social, emotional, spiritual, and
this extensive literature has focused coming increasingly well understood cognitive development.62 Despite this
on the development of cognitive skills, that these dimensions of human devel- bold declaration, an estimated 200 mil-
based on the assumption that they opment are important drivers of eco- lion children under age 5 currently fail
mediate better school performance, nomic welfare generally and of poverty to meet their developmental potential
higher levels of educational achieve- reduction specically.54,55 Consequently, as a result of poverty and undernutri-
ment, increased income, and greater the usual trade-offs between investments tion.14 This gure is 20-fold higher than

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the number of children who die be- complex circuits building on The most widely postulated biological
fore their fth birthday and represents simpler circuits and increas- explanation for these well-established
roughly one-third of all children under ingly complex and adaptive skills associations points to the long-term
age 5 in the world.14 The economic emerging over time. consequences of short-term adapta-
implications of these data are under-  Cognitive, emotional, and social tions in neuroendocrine, autonomic,
scored by recent longitudinal analyses capacities are inextricably inter- immunologic, and neuropsychological
that reported signicant loss of edu- twined, and learning, behavior, and systems78 that are designed to cope
cation and adult earnings attributable both physical and mental health with immediate threat, yet become
to early undernutrition in ve low- and are highly interrelated over the life problematic in the face of excessive
middle-income countries.63 course. activation.4,79 Alterations in electroen-
cephalography tracings and elevated
BUILDING A COORDINATED,  Although manageable levels of
levels of cortisol and norepinephrine in
SCIENCE-BASED APPROACH TO stress are normative and growth-
children exposed to repeated trauma
CHILD SURVIVAL, CHILD promoting, toxic stress in the early
and maltreatment are examples of
DEVELOPMENT, AND LIFELONG years (ie, the physiologic disrup-
such responses.65,80 Converging evi-
HEALTH tions precipitated by signicant
dence from epidemiology and neuro-
adversity in the absence of adult
Although full elucidation of the under- science also indicates that a variety
protection) can damage the devel-
lying causal mechanisms that explain of stresses in early life, including ad-
oping brain and other organ sys-
socioeconomic disparities in health and verse intrauterine inuences such as
tems and lead to lifelong problems
learning awaits further investigation, nutritional deciencies, can cause en-
in learning and social relationships
a rich and growing science of early during abnormalities in brain organi-
as well as increased susceptibility
childhood development is available to zation and structure, as well as in
to illness.
inform the design of more effective endocrine regulatory processes, that
interventions to both increase survival  Brain plasticity and the ability to lead to reduced immune competence
for children born under conditions of change behavior decrease over and higher or less regulated cortisol
signicant disadvantage and improve time, so getting things right the levels, among other consequences.63,81,82
the life prospects of those who do not rst time is less costly, to society Extreme stress and fear in infancy can
die yet face extraordinarily high risks and individuals, than trying to x also result in later patterns of hyper-
for poor outcomes.1 To this end, the them later. vigilance and dysregulated relation-
National Scientic Council on the De-  We have the capacity to measure ships that impair learning, socialization,
veloping Child64 proposed a concep- effectiveness factors that make the and productivity.78
tual framework that draws on the difference between interventions To fully understand the ways in which
following evidence-based principles: that work and those that do not survival, growth, learning, and health
 The architecture of the brain is work to support healthy child de- are interrelated and undermined in com-
constructed through an ongoing velopment. parable ways by signicant adversity, it
process that begins before birth, The link between signicant adversity is essential to understand the central
continues into adulthood, and estab- in childhood and increasing risk for role of the brain in interpreting and
lishes either a sturdy or a fragile later disorders in physical and mental regulating the bodys neuroendocrine,
foundation for all the health, learn- health has been documented exten- autonomic, and immunologic respon-
ing, and behavior that follow. sively.4,6567 Low birth weight and poor ses to stressful events. Stated simply,
 The interaction of genes and expe- infant growth, for example, are asso- the brain is the bodys central control
riences literally shapes the cir- ciated with a range of metabolic dis- center that inuences both physiologic
cuitry of the developing brain, and orders.68 Children who have been and behavioral responses to threat as
is critically inuenced by the mu- neglected, abused, or malnourished well as the development of coping
tual responsiveness of adult-child are more likely to have heart disease skills in the face of adversity.83 More-
relationships, particularly in the as adults.6973 They are also at greater over, the brain is not only an engine
early childhood years. risk for a variety of health-threatening of physiologic change in other organ
 Skill begets skill as brains are behaviors such as smoking and sub- systems, but it is also itself a target
built in a hierarchical fashion from stance abuse, as well as depression of acute and chronic stress, both phys-
the bottom up, with increasingly and anxiety disorders.7477 ical and psychological, and therefore it

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changes both structurally and function- Cushings disease, major depression, continue to respond to ongoing adver-
ally in response to signicant threat.84 and posttraumatic stress disorder, as sity during early childhood in ways that
The biology of adversity and resilience well as in predisease states associated ultimately lead to greater risk of im-
demonstrates that signicant stres- with elevations in circulating inamma- paired health and compromised func-
sors, beginning in utero and continuing tory cytokines.87,88 Moreover, research tionality in the adult years.94,95
throughout the early years, can lead to based on the Barker (thrifty pheno-
early demise or produce long-lasting type) hypothesis has produced con- THE GLOBAL LANDSCAPE FOR
impacts on brain architecture and siderable evidence documenting an CHILD SURVIVAL AND EARLY
function that are associated with later association between adverse fetal con- CHILDHOOD DEVELOPMENT
variations in stress responsiveness, ditions, as reected in relatively lower
The systematic tracking of child mor-
learning, and relationships, as well as birth weight and the subsequent pat-
tality on a global scale began in the
with alterations in health and the rate terning of growth in the rst 2 years 1960s, and efforts to improve survival
of aging. Stress-induced changes have of life, and a variety of poor health rates were accelerated in the early
been well documented in multiple brain outcomes in adulthood. These include 1980s under the vigorous leadership
regions, with the most extensive work increased risk of coronary artery dis- of the United Nations Childrens Fund
focused on the hippocampus (which ease, hypertension, and stroke,72 as (UNICEF). The combined impacts of a
specializes in circuits associated with well as diabetes89 and obesity,90 all of range of interventions during this pe-
simple memory), the amygdala (which which are modied by the speed and riod led to a global drop in under-5
mediates fear and aggression), and the patterning of subsequent growth dur- mortality from an estimated 121 per
prefrontal cortex (which mediates ex- ing childhood, also in response to thousand in 1980 to 88 per thousand in
ecutive functions such as planning and environmental conditions.91 Relatively 1986, saving the lives of some 12 to 25
self-regulation). These changes involve larger birth weight, in contrast, has million children.96,97 Over the ensuing
stress-induced remodeling of neuro- been found to be associated with in- decades, the application of both tradi-
nal structure and connectivity, which creased risk of some hormone-related tional public health principles and new
can alter a range of behavioral and cancers.92 biomedical advances have fueled a
physiologic responses, including anxi- The most widely accepted explanation number of highly effective initiatives,
ety, aggression, mental exibility, and of these ndings has been described and overall child mortality has contin-
memory, among other processes.84 as programming, whereby a spe- ued to decline to an estimated 68 per
When stress response systems are cic exposure during a sensitive period thousand in 2008.98
overactivated during the early years, is hypothesized to exert irreversible, Despite important progress toward
they are programmed to adapt to an long-term effects through epigenetic MDG #4, which is focused on the re-
environment that is expected to re- mechanisms (with or without parallel duction of child mortality, the prema-
main adverse. As a result, the thresh- psychological adaptations) that read ture deaths of .8 million children each
old for activation is lower and the hair the environment in ways that inform year remain a formidable challenge.
trigger nature of the stress response subsequent health or developmental Worldwide, children under 5 are about
results in greater risk for overly rigid processes. In the case of undernutri- four times more likely to die than
and often aggressive behavior. tion, for example, the fetus adapts to adults between 15 and 59 years of
Beyond the impact of stress-induced a condition of scarcity in the intra- age,99101 and 90% of those who die
changes in brain circuitry on behavior, uterine environment to improve its im- before their fth birthday live in the
the consequences for lifelong health mediate chances of survival as a hedge poorest 42 countries in sub-Saharan
and well-being are also apparent. For against future food shortages.93 Such Africa and South Asia.97,102,103 In 2005,
example, functional activation of the adaptations cause permanent changes the World Health Assembly passed a
prefrontal cortex has been shown to in endocrine physiology and metabolic resolution putting maternal and child
be related to changes in blood pres- regulation that result in higher rates health and survival at the top of their
sure, and elevated amygdala activity of obesity in the face of later caloric list of priorities, which was followed
has been linked to the development sufciency, as well as increased risk by substantial budget commitments
of atherosclerosis.85 Reduced hippo- for a variety of adult diseases such as to extend interventions for child sur-
campal volume seen in association with diabetes and hypertension. These same vival.104106 A recent report for the period
years of chronic stress86 has also been physiologic systems can be over- from 2000 to 2010 found that, although
documented in individuals with diabetes, whelmed and result in early death or overseas development assistance for

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maternal, newborn, and child health interventions. The successful imple- extent to which persistent scarcity,
had increased, funding for this sector mentation of these services requires stress, and social instability pose con-
accounted for only 31% of all devel- competent governance, functional facili- tinuing threats to the life prospects of
opment assistance for health in 2007.26 ties and supply chains, a well-trained and children must be a focus for more
In an effort to spur greater progress motivated health care work force, and proactive intervention.
toward meeting MDG goals in this area, additional resources.108 Increasing de- As the science of early childhood de-
the United Nations launched a Global mand through community engagement velopment (ECD) has received increas-
Strategy for Womens and Childrens and mobilization are other critically im- ing recognition globally, the demand
Health in 2010 with a stated objective portant factors inuencing maternal and for greater attention to the needs of
of saving 16 million lives by 2015.107 newborn care in poor countries.109 young children has been incorporated
The major causes of death under the Equally important, and deserving of into several high-prole international
age of 5 in the wealthiest nations increased attention, the biology of documents, including the World Decla-
currently include neonatal conditions, adversity suggests that social inter- ration on Education for All (EFA)110 and
congenital anomalies, motor vehicle ventions that reduce or mitigate the the Dakar Framework for Action,111 the
accidents, and cancer. The most com- physiologic consequences of toxic Millennium Development Goals, and
mon causes of childhood mortality in stress associated with signicant ma- the Report of the World Health Orga-
the poorest countries are diarrhea, terial deprivation (with or without the nization (WHO) Commission on Social
pneumonia, measles, and neonatal con- additional burdens of recurrent abuse, Determinants of Health.112 In 2006,
ditions, with undernutrition as a major chronic neglect, intrafamily and civic UNICEF reported that .30 low- and
underlying contributing factor. Malaria violence, and maternal depression) rep- middle-income countries had estab-
and HIV add signicant additional ca- resent a promising enhancement of lished national ECD policies, and .70
sualties in vulnerable areas. The cur- existing strategies for reducing early nations had some type of national com-
rent knowledge base driving the child childhood mortality. To this end, inter- mission to coordinate ECD programs
survival agenda is grounded in tradi- ventions focused on strengthening the across ministries and sectors.113 These
tional public health principles and the capacities of families to meet their calls for greater investment in young
demonstrated effectiveness of interven- childrens needs in the face of desti- children have been buttressed by in-
tions such as the provision of adequate tution or threat suggest two causal creasing evidence of the effectiveness
nutrition, clean water, sanitation, and pathways to prevent premature death. of early childhood interventions on a
basic medical care; promotion of early The rst is predicated on more effec- range of health and developmental
and exclusive breastfeeding; immuni- tive utilization of preventive and ther- outcomes in low- and middle-income
zation, oral rehydration therapy, and apeutic health services. The second is countries.29,114,115 Within this increas-
vitamin A supplementation; the use of based on the protective inuence of ingly receptive environment, advances
insecticide-treated bed nets to prevent parents ability to promote greater in the biology of adversity offer con-
malaria; and prevention and treat- resilience in their children by facilitat- siderable promise as an additional
ment of HIV/AIDS. Table 1 provides a list- ing effective coping mechanisms in the catalyst to help stimulate the design
ing of recent reviews of interventions face of adversity. and testing of coordinated strategies
designed to improve maternal, new- Building on these efforts, as child mor- to further reduce preventable death
born, and child health and nutrition. tality rates continue to fall, the founda- and to build a foundation for a life-
While it is clear that continuing bio- tional importance of the early childhood time of healthy development.24,32,63,116135
medical research will advance our period for lifelong health and develop- When viewed through this broader
ability to further reduce mortality on ment suggests that survival alone can lens, current medically based inter-
a global scale, important challenges to no longer be a sufcient goal, espe- ventions that are designed primarily to
child survival in the developing world still cially for the poorest countries. Indeed, improve maternal and child survival
remain within the realm of political will the scientic concepts outlined in this are also likely to have positive inuen-
and effective delivery of basic nutrition, article suggest a common underlying ces on child development, yet these
sanitation, and personal health services. vulnerability that leads to a continuum outcomes have not been measured in
These challenges are manifested in the of risk, from early mortality through most evaluations of such programs.
need for existing health systems to deliver a broad spectrum of compromised For example, antenatal services for
an effective combination of health promo- learning as well as impairments in both women that lead to lower rates of in-
tion, disease prevention, and therapeutic physical and mental health. Thus, the trauterine growth retardation24 result

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TABLE 1 Reviews of Interventions Focused on Maternal, Newborn, and Child Health and Nutrition
Review Focus Scope Data Sources Findings/Recommendations
Lancet review of child survival (2003)32 Child mortality under age 5 Comprehensive review 23 interventions Groups of preventive and treatment

SHONKOFF et al
interventions but no delivery
strategies
WHO review of practices that promote Children under age 5 Review of evidence for 12 key practices 12 key practices Underscored importance of linking
child survival, growth, and identied by UNICEF and WHO practices at community level with
development (2004)31 service availability
Lancet review of neonatal outcomes Newborn mortality Community-based interventions review 43 interventions 16 newborn interventions packaged into
(2005)28 (few RCTs) three delivery strategies (community,
outreach, and facility levels)
Lancet review of maternal survival Maternal mortality and morbidity Literature and program review 120 interventions Recommended facility-based skilled
(2006)27 (few RCTs) care at childbirth as the core
intervention
Review of maternal and perinatal Maternal care Literature review and component 84 interventions 5 intervention packages considered
priorities in developing countries analysis for cost-effectiveness (with or without nutritional
(2006)30 supplements)
Lancet review of child development Child and adult cognitive and other Literature and program review 20 programs Recommendation to integrate early child
programs (2007)29 developmental outcomes (few RCTs) stimulation and nutrition programs,
and evaluate at scale
Lancet review of maternal, newborn, Maternal, newborn, and child mortality Literature and delivery strategy review 190 interventions 8 packages of interventions targeted at
and child care (2007)33 for interventions across continuum four levels (household and
of care community, outreach, upper and
lower level facilities)
Lancet review of undernutrition (2008)24 Maternal, newborn, child, and adult Literature and program review 45 interventions Maternal nutrition and supportive
mortality and morbidity due to (RCTs and observational studies) interventions targeted to children
undernutrition during the rst 24 months
Lancet review of primary health care Interventions relevant to maternal, Literature and program review 156 interventions 37 key interventions recommended for
(2008)25 newborn, and child survival and (RCTs & observational studies) inclusion in primary care settings
selected key risk factors
Lancet review of countdown to maternal, Focus on maternal, newborn, and child Review of relevant information from 22 interventions and Better coverage seen with
newborn, and child survival goals survival-related interventions and DHS and MICs data sources respective coverage programmable interventions such as
(2010)26 tracking coverage EPI vaccinations, vitamin A
supplementation, etc.
Lancet review of stillbirths (2011)34 Focus on strategies to inuence fetal Comprehensive review of available 35 interventions 10 evidence-based interventions

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health and growth affecting stillbirths information and trial data recommended for inclusion in
programs in developing countries
including expanded antenatal care for
prevention of pregnancy induced
hypertension, and detection and
management of IUGR and diabetes
RCT, randomized controlled trial; DHS, demographic and health survey; MIC, multiple indicator cluster survey; EPI, expanded program on immunization; IUGR, intrauterine growth retardation.
SPECIAL ARTICLE

in the birth of babies who are at lower childhood intervention by Sameroff lower prevalence of later welfare de-
risk biologically for developmental and Fiese138; the ecological model ar- pendence and incarceration,1 the evi-
impairments. Another example is pro- ticulated by Bronfenbrenner139; and the dence base for successful intervention
vided by interventions that promote concepts of vulnerability and resilience across a broad diversity of nations is
breastfeeding to enhance both nutri- developed by Werner and Smith,140 growing.
tional status and immunologic compe- Garmezy and Rutter,141 and Rutter.142 In low- and middle-income countries,
tence,32,119,125 which are also likely to Together, these frameworks underscore model programs that combine nutrition
promote early developmental progress the extent to which life outcomes are and psychosocial stimulation services
by strengthening maternal-infant inuenced by a dynamic interplay be- have demonstrated the greatest impact
attachment. In a reciprocal fashion, tween the cumulative burden of risk on disadvantaged populations.145 A re-
strategies that focus explicitly on factors and the buffering effects of view of 20 programs that met rigorous
strengthening caregiver-child inter- protective factors that can be identied scientic criteria found that all but
actions and expanding early learning within the individual, family, commu- one (which was delivered at a very low
opportunities in the face of signicant nity, and broader socioeconomic and level of intensity) had positive effects
material deprivation are likely to re- cultural contexts. Each of these models on childrens cognitive development,
duce or mitigate the biological impacts also emphasizes the inuence of re- whereas some also reported gains in
of adversity on very young children, ciprocal child-adult interactions in the social competence, with effect size esti-
thereby enhancing both their survival developmental process, thereby under- mates ranging from 0.3 to1.8.29 A more
and their development. scoring the importance of stable and recent meta-analysis of evidence from
Although the underlying science that nurturing relationships and recognizing 30 interventions utilizing a variety of
supports investment in early child- the active role that young children play approaches in 23 countries in Europe,
hood development has advanced con- in their own development. The chal- Asia, Africa, and Latin America also
siderably, and the literature on effective lenges of actually applying this multi- found moderately positive effects across
demonstration projects in low-income dimensional framework include both multiple developmental domains.146 Of
countries is growing, empirical evidence avoiding the lure of simplistic solutions the models studied, eight provided early
of the successful scale-up of specic and making strategic decisions about education, ve provided child care,
interventions across national and cul- which factors to address and which to ve focused on nutrition, four combined
tural settings is less well developed. omit in designing a specic policy, pro- nutrition and early education, two linked
Moreover, EFA Goal 1 addresses early gram, or empirical study.143 nutrition and child care, one provided
childhood objectives, yet it is the only In response to these challenges, early both early education and child care,
education goal without a quantiable childhood intervention services typically and six focused primarily on cash
indicator against which progress can include nutrition supplements, basic transfers. On average, the magnitude
be measured.136 Similarly, more than health services, and a combination of of the long-term effects was about
half of the worlds governments have nurturing care and enriched learning one-quarter to one-third of a SD, with
ECD policies that are statements of in- opportunities for children, linked to cognitive impacts at the higher end
tent rather than enforceable mandates. a mix of parenting education, emotional (particularly in programs with an ex-
These concerns are compounded by the support, and social protection and so- plicit education component) and posi-
limited number of major international cial services for their families. Over four tive effects sustained through adulthood
donors who have identied ECD as decades of program development and when long-term data were obtained.114
a specic focus, the majority of whom evaluation, this approach has been Recent modications of conventional
allocate ,2% of their education fund- implemented in demonstration projects ECD programs have included greater
ing to the early childhood years.136 around the world that have conrmed attention to nancial and social pro-
Over the past several decades, early the ability to produce signicant impacts tection for parents, increasing focus
childhood policies and practices have across a range of outcomes.144 Although on confronting violence against women
been guided by several theoretical mod- much of the empirical literature has and young children, and the promo-
els of human development that have come from the United States, where tion of positive engagement of men in
been rened over time. These include positive returns on investment have addressing family needs. These and
the transactional model formulated by been documented in cost savings from other program models have been
Sameroff and Chandler137 and later decreased grade retention and refer- delivered through a variety of mecha-
adapted to the challenges of early rals for special education as well as nisms including home visiting, primary

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health facilities,146,147 and group ses- for Economic Cooperation and De- gies for reducing mortality reveals a
sions with caregivers.148 In this context, velopment (OECD) estimated per capita remarkable overlap with many of the
a broader range of social interventions, expenditures on children in the rst 18 key characteristics of interventions
such as conditional and unconditional years of life at $126 000, with an average that are effective in promoting healthy
cash transfers, microcredit schemes, of only 24% spent during the period development, which typically add the
and voucher programs, are increasingly from birth to age 5, compared with 36% essential element of enriched learning
being adopted to meet the needs of spent from age 6 to 11 and 41% from opportunities in the early years of life.
disadvantaged, young children around age 12 to 17.154 Comparable data on Central to both objectives is the im-
the world. Conditional cash transfers human capital investment in developing portance of preventing, reducing, or
appear to be a particularly promising countries are not available, yet the gaps mitigating the adverse physiologic con-
strategy to expand ECD impacts, be- between human needs and available sequences of toxic stress, which can
cause they improve the immediate, resources are known to be considerable range from the life-threatening con-
material circumstances of poor families at all age levels. This situation is most sequences of compromised immune
(by providing money), while also en- severe in sub-Saharan Africa, where the function to the impaired learning that
hancing the life prospects of the chil- absolute poverty rate for children is the results from disrupted brain circuitry.
dren by having the conditions linked to highest in the world, the rate of growth Stated simply, the future of more ef-
services that strengthen their health, stunting exceeds 30%, and only 12% fective early childhood policy calls for
nutrition, and early educational experi- of children are enrolled in preschool a balanced approach to both stimu-
ences. Evaluations of these programs compared with an average rate globally lating minds and protecting brains.156
have documented positive impacts on of 32% in developing countries and 74% Recent reports from the American
childrens nutritional status;149 encour- for developed nations.155 In 21 of the 48 Academy of Pediatrics call for new
aging evidence of their ability to address countries in the region, infant mortality approaches to health promotion
critical child needs in resource-poor is well above 100 per thousand. In the based on this concept.157,158
settings or areas that have been Within this context, as ministries of
realm of education, gross primary en-
struck by extreme adversity such as health continue to prioritize child sur-
rollment rates approach 100% in many
internal wars or large-scale epi- vival, ministries of education focus on
countries, but primary grade completion
demics150,151; and promising reports of
remains below 50% in one-third of them schooling, and ministries of nance
their implementation in sub-Saharan promote economic development, an in-
and preprimary enrollment is typically in
Africa.152,153 For societies that are bur- tegrated biology of adversity offers a
the single digit range or nonexistent.155
dened by the highest levels of material compelling knowledge base that could
deprivation and political instability, the Science tells us that the foundations of
inform a unifying strategy across policy
need for more innovative approaches lifelong health and learning are built
sectors. The fruits of that synergy, a
that go beyond the provision of conven- in the earliest years of life. Therefore,
healthy and well-educated population,
tional health care and early childhood the time has come to match continuing
secure and well-functioning commu-
programs clearly remains a particularly progress in the global reduction of child
nities, and a prosperous and self-
compelling challenge. In such circum- mortality with greater investment in
sustaining society, will be harvested
stances, an integrated science of early the universal promotion of early child- by those nations that make science-
childhood health and development offers hood development, particularly in the based investments in the healthy de-
a powerful framework within which poorest nations. Sustainable gains in velopment of their youngest members.
creative new strategies can be formu- child survival have been generated by
lated, tested, and rened over time. social interventions and health care ACKNOWLEDGMENTS
initiatives that focus on improving the Dr Shonkoff gratefully acknowledges
CONCLUDING COMMENTS physical and mental health of mothers, the Norlien Foundation, the Pierre and
Extensive documentation of the value promoting the stability and security of Pamela Omidyar Fund, and the Mother
of investing in healthy development families, supporting child nutrition, en- Child Education Foundation (AEV) of
beginning at birth (and indeed, pre- suring child protection against signi- Turkey, each of which has provided -
natally) stands in stark contrast to cant adversity, securing basic health nancial support for the global portfolio
current policies regarding human capi- services of good quality, and building of the Center on the Developing Child
tal formation in virtually every nation culturally compatible bridges between at Harvard University, whose infra-
in the world. A recent study of child well- service programs and homes. A sys- structure and stafng supported the
being in 28 countries in the Organization tematic analysis of these core strate- authors.

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e472 SHONKOFF et al
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An Integrated Scientific Framework for Child Survival and Early Childhood
Development
Jack P. Shonkoff, Linda Richter, Jacques van der Gaag and Zulfiqar A. Bhutta
Pediatrics 2012;129;e460
DOI: 10.1542/peds.2011-0366 originally published online January 4, 2012;

Updated Information & including high resolution figures, can be found at:
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
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An Integrated Scientific Framework for Child Survival and Early Childhood
Development
Jack P. Shonkoff, Linda Richter, Jacques van der Gaag and Zulfiqar A. Bhutta
Pediatrics 2012;129;e460
DOI: 10.1542/peds.2011-0366 originally published online January 4, 2012;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/129/2/e460

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright 2012 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .

Downloaded from http://pediatrics.aappublications.org/ by guest on September 19, 2017

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