Elsevier

The Lancet

Volume 389, Issue 10064, 7–13 January 2017, Pages 91-102
The Lancet

Series
Nurturing care: promoting early childhood development

https://doi.org/10.1016/S0140-6736(16)31390-3Get rights and content

Summary

The UN Sustainable Development Goals provide a historic opportunity to implement interventions, at scale, to promote early childhood development. Although the evidence base for the importance of early childhood development has grown, the research is distributed across sectors, populations, and settings, with diversity noted in both scope and focus. We provide a comprehensive updated analysis of early childhood development interventions across the five sectors of health, nutrition, education, child protection, and social protection. Our review concludes that to make interventions successful, smart, and sustainable, they need to be implemented as multi-sectoral intervention packages anchored in nurturing care. The recommendations emphasise that intervention packages should be applied at developmentally appropriate times during the life course, target multiple risks, and build on existing delivery platforms for feasibility of scale-up. While interventions will continue to improve with the growth of developmental science, the evidence now strongly suggests that parents, caregivers, and families need to be supported in providing nurturing care and protection in order for young children to achieve their developmental potential.

Introduction

Although global attention to early childhood development has been established through its inclusion in the UN Sustainable Development Goals, 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of not achieving their developmental potential, as discussed in Paper 1 of this Series.1 We suggest that this gap in human potential is partly due to two reasons: the failure to apply emerging scientific knowledge on nurturing care to shape young children's development; and the failure to take action at scale, using a multi-sector approach across key stages in the early life course.

We define nurturing care as a stable environment that is sensitive to children's health and nutritional needs, with protection from threats, opportunities for early learning, and interactions that are responsive, emotionally supportive, and developmentally stimulating. As an overarching concept, nurturing care is supported by a large array of social contexts—from home to parental work, child care, schooling, the wider community, and policy influences.2 Nurturing care consists of a core set of inter-related components, including: behaviours, attitudes, and knowledge regarding caregiving (eg, health, hygiene care, and feeding care); stimulation (eg, talking, singing, and playing); responsiveness (eg, early bonding, secure attachment, trust, and sensitive communication); and safety (eg, routines and protection from harm).3, 4 The single most powerful context for nurturing care is the immediate home and care settings of young children often provided by mothers, but also by fathers and other family members, as well as by child-care services.

The brain has evolved to adapt in response to a wide range of early experiences, which supports the rapid acquisition of language, cognitive skills, and socio-emotional competencies. Nurturing care mediates the development of key brain regions and promotes developmental adaptations. These developments have lifelong benefits for children, including an increased ability to learn, greater achievement in school and later life, citizenship, involvement in community activities, and overall quality of life.5, 6 The period of early development is one of enormous change and is characterised by a high degree of plasticity in brain organisation.7, 8 Advances in developmental science have also provided an understanding of the multiple and overlapping critical windows of time when development of specific capacities and abilities is most powerfully enhanced.9, 10 Nurturing, caring, enriching, and protective interactions provide the early environments needed for developmental progression to occur, and protect infants and children from the negative effect of stress and adversity (panel 1). Studies from across the globe, including from Jamaica,17, 18, 19 Pakistan,20 and Turkey,21, 22 have demonstrated that including elements of nurturing care in interventions significantly improves childhood development and even later adult outcomes (appendix pp 22–25). The interplay between the elements of nurturing care, the timing of experiences, and complexity of risks requires action beyond single sector interventions.

Key messages

  • Advances in basic and intervention science indicate that early childhood is a period of special sensitivity to experiences that promote development, and that critical time windows exist when the benefits of early childhood development interventions are amplified.

  • The most fundamental promotive experiences in the early years of life come from nurturing care and protection received from parents, family, and community, which have lifelong benefits including improved health and wellbeing, and increased ability to learn and earn.

  • Nurturing care and protection are supported by a range of interventions delivered pre-pregnancy and throughout birth and the newborn period, infancy, and early childhood. Many of these interventions have shown benefits for child development, nutrition, and growth, and reductions in morbidity, mortality, disability, and injury.

  • Interventions that integrate nurturing care and protection can target multiple risks to developmental potential at appropriate times, and can be integrated within existing preventive and promotive packages.

  • Preventive and promotive packages can build on existing platforms, such as community-based strategies and social safety nets, for delivering parental and child services at scale to vulnerable and difficult-to-reach populations, enhancing their effectiveness and sustainability.

Section snippets

Selection of interventions for review

This paper provides a comprehensive update of early childhood development interventions across key sectors. Although progress has been made with early childhood development-related interventions, existing research is at different levels of maturity across sectors and distributed across numerous populations and settings. Experts from research communities in reproductive, maternal, newborn, and child health (RMNCH), nutrition, parenting, early childhood education, maltreatment prevention, and

Interventions encompassing the period before conception to birth

We did a comprehensive review of 40 interventions related to early childhood development across diverse sectors, and found 15 types of interventions that show benefit on multiple outcomes including child development, based on high-quality systematic reviews (table). Many of those with effects on childhood development encompass aspects of nurturing care including parenting support and social protection, care for the caregiver, and early learning opportunities provided in or out of the home

Parenting support

Opportunities for stimulation, responsive parent–child interactions, child-directed and focused enrichment, early learning, and positive parenting are crucial for children's development.30 Parenting programmes are operationally defined as interventions or services aimed at improving parenting interactions, behaviours, knowledge, beliefs, attitudes, and practices. Three recent reviews31, 32, 36 of parenting programmes in LMICs found positive effects on direct measures of children's cognitive and

Intervention packages that integrate nurturing care with sector-specific programmes

Building on the earlier Lancet child development Series, the subsequent literature on early childhood interventions has expanded to include new longitudinal data and cohort data from LMICs. Most interventions during the period from preconception to birth focus on the physical and mental health of the mother to support a healthy pregnancy and improve birth outcomes. Interventions focusing on nurturing care and protection are usually introduced at birth; however, maternal programming for

Building on sectoral services

Multi-sector approaches include coordinated services across sectors, for example water and sanitation, ideally with unifying policies. Integrated approaches refer to integration across services with shared messages and opportunities for synergy, as discussed in Paper 1 of this Series.1 Many sectoral interventions could serve as the basis for delivery of services that link policy level strategies of cash transfer, social policies, and income generation with programmatic interventions, such as

Delivering multi-sectoral intervention packages to improve childhood development

The effect of interventions on early childhood development could be improved by taking into consideration the major insights we have gained over the past decade about how human development is affected by complex and multi-faceted experiences, starting with previous generations. Based on the science of early human development, we need to conceptualise meaningful integration of interventions through a coordinated approach. In instances in which sectoral interventions were combined with elements

Future research areas

Although there has been progress in the understanding of what interventions work, there are major gaps in knowledge. The particular set of risks faced by children in conflict is not well understood. There is also a lack of knowledge about the effectiveness of early childhood development interventions in conflict-affected and fragile countries. We need to improve our understanding of how to: better combine interventions through robust assessment of intervention outcomes and evaluations of

Conclusion

In this paper we call for meaningful integration across sectoral interventions, through programmatic packages that promote nurturing care and protection to improve developmental outcomes. We also call for better integration of evidence-based interventions within health-care and nutrition sectors. The results of our literature review suggest that successful, smart, and sustainable interventions to improve developmental outcomes need to: promote nurturing care and protection; be implemented as

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