Promoting Early Child Development WithTyler Vaivada, MSc, Interventions a Michelle F. Gaffey, MSc, a Zulfiqar A. Bhutta, in PhD a,Health b and CONTEXT: Nutrition: A Systematic Reviewabstract Although effective health and nutrition interventions for reducing child mortality and morbidity exist, direct evidence of effects on cognitive, motor, and psychosocial OBJECTIVE: development is lacking. To review existing evidence for health and nutrition interventions affecting direct DATA SOURCES: measures of (and pathways to) early child development. Reviews and recent overviews of interventions across the continuum of care and STUDY SELECTION: component studies. We selected systematic reviews detailing the effectiveness of health or nutrition interventions that have plausible links to child development and/or contain direct DATA EXTRACTION: measures of cognitive, motor, and psychosocial development. RESULTS: A team of reviewers independently extracted data and assessed their quality. Sixty systematic reviews contained the outcomes of interest. Various interventions reduced morbidity and improved child growth, but few had direct measures of child development. Of particular benefit were food and micronutrient supplementation for mothers to reduce the risk of small for gestational age and iodine deficiency, strategies to reduce iron deficiency anemia in infancy, and early neonatal care (appropriate resuscitation, delayed cord clamping, and Kangaroo Mother Care). Neuroprotective interventions for imminent preterm birth showed the largest effect sizes (antenatal corticosteroids for developmental delay: risk ratio 0.49, 95% confidence interval 0.24 to 1.00; magnesium LIMITATIONS: sulfate for gross motor dysfunction: risk ratio 0.61, 95% confidence interval 0.44 to 0.85). Given the focus on high-quality studies captured in leading systematic reviews, CONCLUSIONS: only effects reported within studies included in systematic reviews were captured. These findings should guide the prioritization and scale-up of interventions within critical periods of early infancy and childhood, and encourage research into their implementation at scale. aCentre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada; and bCenter of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan Mr Vaivada designed the study protocol, coordinated data extraction, and drafted the initial manuscript; Ms Gaffey designed the study protocol and data analysis plan and critically reviewed and revised the manuscript; Dr Bhutta conceptualized and designed the study, obtained funding, oversaw the data abstraction and analysis, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. DOI: https:// doi. org/ 10. 1542/ peds. 2016- 4308 To cite: Vaivada T, Gaffey MF, Bhutta ZA. Promoting Early Child Development With Interventions in Health and Nutrition: A Systematic Review. Pediatrics. 2017;140(2):e20164308 Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 140, number 2, August 2017:e20164308 REVIEW ARTICLE Despite recent improvement, in children <5 years old, high rates of mortality and morbidity, poverty, and chronic undernutrition are pervasive in many low- and middle- income countries (LMIC). For children who survive infancy, many remain at a high risk for stunted growth and impaired development. In 2014, ~23.8% of children (159 million) <5 years old were stunted1 Lancet’ and at a high risk2 of impaired child development. The s 20163 Early Child Development Series estimated that based on stunting and extreme poverty, 43% of children (249.4 million) <5 years old in LMIC were at 4risk for suboptimal development, which effectively FIGURE 1 forfeits a quarter of the annual adult Conceptual framework of the risk factors in early life for suboptimal child growth and development. income because of lost cognitive The dotted box highlights the focus of this overview on interventions that address biological risk 5 factors. potential and reduced productivity. Recent predictive modeling that used the Human Development Index, nutrition status, and Early Child evidence for an intergenerational number of children surviving infancy, Development Index data (from the impact of early11 stunting on child the importance 7of enhancing the Multiple Indicator Cluster Survey development and a potential survival agenda to reduce morbidity and Demographic Health Survey) second window of opportunity for and support child development is suggests that 36.8% of children supporting development12 in the evident. (80.8 million) ages 3 to 4 years in adolescent period. LMIC do not reach fundamental Table 1 summarizes the theoretical cognitive or socioemotional6 A variety of interventions that rationale for the beneficial development milestones. Moving support maternal, newborn, and child neurodevelopmental impacts of a forward, achieving the Sustainable health and nutrition (MNCH&N) have variety of interventions at various Development Goals of zero hunger been identified as both effective and time points. Particularly impactful (Goal 2), good health and well-being feasible for scale-up. The rationale targets ameliorate maternal “ ” at all ages (Goal 3), and quality for focusing on interventions that malnutrition and infection during and equitable education (Goal 4) target the First 1000 Days of preconception and pregnancy, will require maximizing every life (from conception to 2 years of which contribute to intrauterine opportunity to institute appropriate age) is that the mitigation of risk growth restriction (IUGR), children interventions at scale. factors during this critical period being born small for gestational has substantial13 benefits over the age (SGA), or preterm births, and To assist in selecting and prioritizing life course. There is evidence to neonatal infections. In addition to key interventions, we developed suggest, however, that this period the developmental risks associated10 a conceptual framework of risk may be somewhat arbitrary because with maternal iodine deficienc14 y factors and– opportunities for highly effective interventions also and folic acid deficiency, recent interventions7 9 across the life course exist for the preconception period, evidence demonstrating the link (Fig 1). For this overview, we late childhood, and adolescence between Zika virus infection were focused on the biological that could benefit developmental during pregnancy and subsequent15 risk factors for suboptimal outcomes. Nevertheless, supporting microcephaly in some infants development, which broadly include development in utero and early life highlights the potential infectious 16 undernutrition, infectious10 disease, is important and is when much of risks to neurodevelopment in utero. and toxin exposure, many of the fetal morbidity, stillbirths, and Postnatally, reducing environmental which affect both child7 survival <5 years of age3 child mortality is enteropathy is key because it may and development. There is also concentrated. With an increasing mediate the relationship between Downloaded from www.aappublications.org/news by guest on September 29, 2021 2 VAIVADA et al TABLE 1 Theoretical Rationale for the Neurodevelopmental Impact of MNCH&N Interventions Through a Reduction in Risk Factors poor personal and food hygiene Intervention Targets Potential Mechanisms for Impact and environmental factors that Improving maternal Reduce inflammation and protect a developing fetus by preventing and contribute to developmental deficits physical, mental treating infection.9, 16, 23 through chronic intestinal17 mucosal, health, and nutritional Protect a fetus from maternal hormonal imbalances and deleterious 24 systemic inflammation, 18 and status epigenetic changes by reducing chronic stress and preventing and nutrient malabsorption. Both acute treating depression.25 malnutrition and stunted growth in Prevent IUGR and support optimal gestational growth and development by ensuring adequate food and micronutrient intake, particularly iodine and childhood are associated with poorer19 iron.10 cognitive and motor development. Improving birth Protect against neurologic damage by reducing the risk of preterm birth and Despite these obvious links, most outcomes and complications associated with prematurity.26 studies or programs of MNCH&N reducing incidence Ensure skilled birth attendance and hygienic delivery practices to prevent 23 interventions typically only of newborn neurologic harm from sepsis. complications, Reduce complications and neurologic damage from birth asphyxia and measure proximal measures, such neonatal infection associated hypoxia23 by preventing obstructed labor, being large for as anthropometry, birth outcomes, gestational age, or postmature births and providing emergency cesarean or clinically apparent health deliveries and effective resuscitation when required. outcomes. The associations between Special care for preterm Enhance lung adaptation and neuroprotection for vulnerable fetuses before 27 these intermediate outcomes and and SGA infants imminent preterm birth with antenatal corticosteroids and magnesium sulfate.28 brain development are not only Provide appropriate thermal care and support prevention of neonatal biologically plausible20 but have been infection, especially in preterm neonates who are vulnerable.29, 30 demonstrated,21 and they22 include Delay cord clamping to maximize umbilical