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![Page 1: S Grantham-McGregor Centre for Health and Development, Institute of Child Health, University College London Child development in developing countries.](https://reader030.fdocuments.in/reader030/viewer/2022012922/56649cfd5503460f949cd778/html5/thumbnails/1.jpg)
S Grantham-McGregorCentre for Health and Development, Institute of Child Health,
University College London
Child development in developing countries
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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)
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
1.The size of the problem2.The causes
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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.
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Aims of paper
• Estimate the size of the problem
• Identify the location of affected children
• Estimate cost and consequences
• Factors causing poor development
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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
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Sensory-motor
Cognitive-language
Social-emotional
Domains of Child Development
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Major problem with estimating numbers of affected children
• Insufficient data on early cognitive ability for most developing countries to estimate prevalence
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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)
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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 ?
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Stunting in children
> 28 studies X-sectional associations between stunting & poor cognition or schoolachievement
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Longitudinal data essential
Jamaica Walker
South African Richter, Norris
Phillipines Cebu study
Uganda data Family Life Study
Brazil Victora, Barros, Damiani, Lima, Gigante, Horta
Peru Berkman, Lescano
Guatemala Martorell
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Cognitive or schooling deficits associated with moderate stunting <3yrs in 7 longitudinal studies
-1.5
-1.1
-0.7
-0.3
0.1
0.5
Philippines S Africa Indonesia Brazil Peru Jamaica Guatemala7yrs 7yrs 9yrs 17-18yrs18yrs15yrs 18-25yrs
SD scores
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Reasonable to use stunting as an indicator of poor child development
Conclusion
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Poverty <1 per day
>60 X-sectional studies showed associations with wealth and school achievement or cognition
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Later cognitive deficits associated with being in the lowest wealth quintile <3yrs in 5 longitudinal
studies (SD scores)
-1.5
-1.1
-0.7
-0.3
0.1
0.5
Philippines Indonesia S Africa Brazil^ Guatemala*
^Grades attained *boys
15yrs 7yrs 7yrs 18yrs 18-26yrs
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Reasonable to use poverty as an indicator of poor child development
Conclusion
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Millions of children < 5y not fulfilling their potential in development (WHO, 2006; UNICEF 2006)
0
50
100
150
200
250
Stunted Poverty Disadvantaged
156m
126m
219m (39% of children <5y)
Stunted +Poverty not stunted
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% of disadvantaged children <5yrs by region
0
10
20
30
40
50
60
70
S-S Africa Mid East & NAfrica
S Asia E Asia &Pacific
La America &Caribbean
Central & EEurope
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Limitations
• Other risk factors not included
• Cut off for poverty uncertain
• Estimate for numbers of children based on
poverty rates for total population
Underestimate
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1. 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
Loss of yearly adult income
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Loss of yearly adult income
Deficit in grades attained
Deficit in learning per grade
% loss of yearly adult income
Mean %
Stunted 0.91 2.0 22.2
19.8%Poor 0.71 ??? 5.9
Stunted & poor
2.15 2.0 30.1
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Conclusion
Loss of children’s potential is an enormous problem affecting >200million
It has economic and social costs both to individual and nations
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Risk factors affecting child development in low resource countries
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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
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Four main risks
Chronic undernutrition leading to stunting
Iodine deficiency
Iron deficiency anemia (IDA)
• Inadequate cognitive stimulation
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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, oppositionalWalker et al 2005, 2006
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Inadequate cognitive stimulation or learning
opportunities
A biological insult
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Mean Corticosterone Levels Pre & Post Stress in Non-handled, Handled and Maternally-separated Rats
0
5
10
15
20
25
30
35
40
0 60 120
non-handled
maternal separation
handled
0
5
10
15
20
25
30
35
40
0 60 120
non-handled
maternal separation
handled
Plotsky & Meaney 1993
µg/dl
Pre-Pre-stressstress
Time (min)Time (min)
(n= 8 per group)
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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
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Effects of Effects of visiting frequencyvisiting frequency in in disadvantaged children disadvantaged children
DQ
Powell & Grantham-McGregor, 1989Powell & Grantham-McGregor, 1989
fortnightlyfortnightly
monthlymonthly
no visitsno visits
94
98
102
106
110
Pre-testPre-test Post-testPost-test
weeklyweekly
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75
80
85
90
95
McKay et al, 1979McKay et al, 1979
Cognitive abilityCognitive ability
Cognitive ability at 7 years Cognitive ability at 7 years by durationby duration of center of center based intervention; Colombiabased intervention; Colombia
0
1 2 3 4
Periods of interventionPeriods of intervention
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Interventions with stunted Interventions with stunted childrenchildren
85
90
95
100
105
110
Baseline 6 mo 12 mo 18 mo 24 mo
85
90
95
100
105
110
Baseline 6 mo 12 mo 18 mo 24 mo
DQDQnon-stuntednon-stunted
controlcontrol
Grantham-McGregor et al, 1991Grantham-McGregor et al, 1991
both Rxs
supplemented
stimulated
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Sustained: Benefits at 17-18 Years From Early Childhood Stimulation in Stunted Children
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
Visual spatialDigit span FDigit span B
ArithmeticReading comp
Sent compVocabulary
AnalogiesReasoningPerform IQ
Verbal IQGlobal IQ
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
Visual spatialDigit span FDigit span B
ArithmeticReading comp
Sent compVocabulary
AnalogiesReasoningPerform IQ
Verbal IQGlobal IQ
Standard scoresStandard scores
P valueP value
Walker et al, 2005Walker et al, 2005
********************
****** ******nsnsnsnsnsnsnsns
*p<.1; **p*p<.1; **p<<.05, ***p.05, ***p<<.01.01
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Sustained: Benefits at 17-18 years from stimulation in early childhood in stunted children
0 0.1 0.2 0.3 0.4 0.5
Oppostional behaviour
Hyperactivity
Inattention
Attention deficit
Antisocial
Self esteem
Depression
Anxiety
0 0.1 0.2 0.3 0.4 0.5
Oppostional behaviour
Hyperactivity
Inattention
Attention deficit
Antisocial
Self esteem
Depression
Anxiety
Standard scoresStandard scores
****
****
****
nsns
****
nsns
nsns
**
P value
Walker et al unpublishedWalker et al unpublished*p<.1; **p*p<.1; **p<<.05.05
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• Consistent concurrent benefits to child’s DQ Consistent concurrent benefits to child’s DQ
• Benefits greater in :Benefits greater in :
more intense, longer, include nutrition more intense, longer, include nutrition
• Sustainable cognitive,education and mental Sustainable cognitive,education and mental health benefits at 17-18yrshealth benefits at 17-18yrs
Summary of stimulation studies
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Conclusion: Good evidence for 4 main risks
Chronic undernutrition leading to stunting
Iodine deficiency
Iron deficiency
Inadequate cognitive stimulation
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Other risk factors
• Risk factors with consistent epidemiological evidence showing association with development
• Lack of interventions with evaluation of effectiveness
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Other risks identified
Small for gestational age
Malaria
Maternal depression
Exposure to violence
Exposure to environmental toxins
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Multiple risks in early childhood and achievement scores in adolescence
-1
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
0 2 4 6 8
SD
sco
res
Reasoning Achievement
Gorman and Pollitt, 1996Gorman and Pollitt, 1996
Risk factors
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Mean Developmental Quotients on Griffiths TestMean Developmental Quotients on Griffiths Test
90
100
110
120
6 to 17 18 to 29 30 to 41 42 to 53 54 to 59
DQ
Age months
Urban middle class Urban middle class n=78n=78
Urban poor Urban poor n=268n=268
(Walker et al)
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Poverty
Poor care and home stimulation
Maternal stress/depressionLow education
Poor cognitive,socio-emotional development
Stunting & wasting, iodine & iron deficiency, diarrhoea, infections
Poor school achievement
Poor sanitation, Food insecurity
Poor hygiene,feeding practices,care-seeking
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Childpoor early development
poor school achievementbehavioural problemspoor stimulation,
nutrition & health
Intergenerational transmission of poverty
adultlow educational attainment
low skilled job / no work high fertility
depressed/stressed
nationaleconomy
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Countries with highest % of children < 5y who are stunted in Latin America & the Caribbean
(UNICEF 2006)
0
10
20
30
40
50
60
Guatem
ala
Hondura
s
Bolivia
Ecuador
PeruHai
ti
Nicara
gua
LA &
Car
ib
Develo
ping
%
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Types of evidence
1. Randomised trials and intervention studies
2. Prospective cohort studies
3. Associational studies (with control for confounders)
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Vocabulary scores by SES quartiles in 36 to 72
month old children Equador Paxson and Shady 2005
age in months
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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
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Why psychosocial stimulation interventions?
• Malnourished children do not catch up with nutrition Malnourished children do not catch up with nutrition alonealone
• Stimulation changes brain function in animalsStimulation changes brain function in animals
• Adoption studies show vast improvement Adoption studies show vast improvement
• In USA disadvantaged children have shown sustained In USA disadvantaged children have shown sustained benefitsbenefits
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IQ scores of stunted and non-stunted Jamaican children from age 9-24 mo to 18 y
Non-stuntedNon-stunted
Stunted.Stunted.
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Griffiths onGriffiths onEnrollmentEnrollment((9-24 mo)9-24 mo)
GriffithsGriffiths(33-48 mo)(33-48 mo)
Stanford-Stanford-BinetBinet(7-8 y)(7-8 y)
WISC-RWISC-R(11-12 y)(11-12 y)
WAISWAIS(17-18 y)(17-18 y)
SD
sco
reS
D s
core
Walker et al 2005
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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