Every Child's Potential

Early Childhood Development Resources

Integrated interventions for optimal growth and development

Caulfield LE, Putnick DL, Zavaleta N, et al. Maternal gestational zinc supplementation does not influence multiple aspects of child development at 54 mo of age in Peru. Am J Clin Nutr. 2010;92(1):130-6.

Christian P, Black RE. Food, micronutrients, and birth outcomes. JAMA. 2012;307(19):2094-6.

De Onis M, Blössner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr. 2010;92(5):1257-64.

De Onis M, Blössner M, Borghi, E. Prevalence and trends of stunting among preschool children, 1990–2020. Publ Health Nutr. 2012;15(1):142-8.

Grantham-McGregor S, Cheung YB, Cueto S, et al. Developmental potential in the first 5 years for children in developing countries. Lancet. 2007;369(9555):60-70.

Murray-Kolb LE, Khatry SK, Katz J, et al. Preschool micronutrient supplementation effects on intellectual and motor function in school-aged Nepalese children. Arch Pediatr Adolesc Med. 2012 May;166(5):404-10.

Ramakrishnan U, Goldenberg T, Allen LH. Do multiple micronutrient interventions improve child health, growth, and development? J Nutr. 2011;141(11):2066-75.

Shonkoff JP, Richter L, van der Gaag J, Bhutta ZA. An integrated scientific framework for child survival and early childhood development. Pediatrics. 2012;129(2):e460-72.

Thompson RA, Nelson CA. Developmental science and the media: early brain development. Am Psychol. 2001;56(1):5-15.

UNICEF–WHO–The World Bank. Joint child malnutrition estimates—levels and trends. 2012.

Victora CG, de Onis M, Hallal PC, et al. Worldwide timing of growth faltering: revisiting implications for interventions. Pediatrics. 2010;125:e473-e480.

Walker SP, Wachs TD, Grantham-McGregor S, et al. Inequality in early childhood: risk and protective factors for early child development. Lancet. 2011;378(9799):1325-38.

Timing of integrated early interventions

Anda RF, Butchart A, Felitti VJ, Brown DW. Building a framework for global surveillance of the public health implications of adverse childhood experiences. Am J Prev Med. 2010;39(1):93-8.

Bercik P, Verdu EF, Foster JA, et al. Chronic gastrointestinal inflammation induces anxiety-like behavior and alters central nervous system biochemistry in mice. Gastroenterology. 2010;139(6):2102-2112.e1.

Engle PL, Pelto GH. Responsive feeding: implications for policy and program implementation. J Nutr. 2011;141(3):508-11.

Hackman DA, Farah MJ. Socioeconomic status and the developing brain. Trends Cogn Sci. 2009;13(2):65-73.

Hertzman C, Boyce T. How experience gets under the skin to create gradients in developmental health. Annu Rev Public Health. 2010;31:329-47.

Juffer F, van Ijzendoorn MH. Behavior problems and mental health referrals of international adoptees: a meta-analysis. JAMA. 2005;293(20):2501-15.

Lambek R, Shevlin M. Working memory and response inhibition in children and adolescents: age and organization issues. Scand J Psychol. 2011;52(5):427-32.

Lewis TL, Maurer D. Multiple sensitive periods in human visual development: evidence from visually deprived children. Dev Psychobiol. 2005;46(3):163-83.

Love JM, Chazan-Cohen R, Raikes H, Brooks-Gunn J. What makes a difference: Early Head Start evaluation findings in a developmental context. Monogr Soc Res Child Dev. 2013;78(1):vii-viii, 1-173.

Lupien SJ, McEwen BS, Gunnar MR, Heim C. Effects of stress throughout the lifespan on the brain, behavior and cognition. Nat Rev Neurosci. 2009;10(6):434-45.

McEwen BS, Stellar E. Stress and the individual. Mechanisms leading to disease. Arch Intern Med. 1993;153(18):2093-101.

Rueda MR, Posner MI, Rothbart MK. The development of executive attention: contributions to the emergence of self-regulation. Dev Neuropsychol. 2005;28(2):573-94.

Turnbaugh PJ, Hamady M, Yatsunenko T, et al. A core gut microbiome in obese and lean twins. Nature. 2009;457(7228):480-4.

Combining child development with nutritional or health interventions

Aboud FE, Akhter S. A cluster-randomized evaluation of a responsive stimulation and feeding intervention in Bangladesh. Pediatrics. 2011;127(5):e1191-7.

Aboud FE. Evaluation of an early childhood parenting program in rural Bangladesh. J Health Popul Nutr. 2007;25(1):3-13.

Bernal R, Fernández C. Subsidized childcare and child development in Colombia: effects of Hogares Comunitarios de Bienestar as a function of timing and length of exposure. Soc Sci Med. 2012. [Epub ahead of print]

Hamadani JD, Huda SN, Khatun F, Grantham-McGregor SM. Psychosocial stimulation improves the development of undernourished children in rural Bangladesh. J Nutr. 2006;136(10):2645-52.

Lozoff B, Smith JB, Clark KM, et al. Home intervention improves cognitive and social-emotional scores in iron-deficient anemic infants. Pediatrics. 2010;126(4):e884-94.

Nahar B, Hamadani, JD, Ahmed T, et al. Effects of psychosocial stimulation on growth and development of severely malnourished children in a nutrition unit in Bangladesh. Eur J Clin Nutr. 2009;63(6):725-31.

Nahar B, Hossain MI, Hamadani JD, et al. Effects of a community-based approach of food and psychosocial stimulation on growth and development of severely malnourished children in Bangladesh: a randomized trial. Eur J Clin Nutr. 2012;66(6):701-9.

Ogunlade AO, Kruger HS, Jerling JC, et al. Point-of-use micronutrient fortification: lessons learned in implementing a preschool-based pilot trial in South Africa. Int J Food Sci Nutr. 2011;62(1):1-16.

Powell C, Baker-Henningham H, Walker S, et al. Feasibility of integrating early stimulation into primary care for undernourished Jamaican children: cluster randomized controlled trial. BMJ. 2004;329(7457):89.

Vazir S, Engle P, Balakrishna N, et al. Cluster-randomized trial on complementary and responsive feeding education to caregivers found improved dietary intake, growth and development among rural Indian toddlers. Matern Child Nutr. 2013;9(1):99-117.

Waber DP, Vuori-Christiansen L, Ortiz N, et al. Nutritional supplementation, maternal education, and cognitive development of infants at risk of malnutrition. Am J Clin Nutr. 1981;34(Suppl 4):807-13.

Walker SP, Powell CA, Grantham-McGregor SM, et al. Nutritional supplementation, psychosocial stimulation, and growth of stunted children: the Jamaican study. Am J Clin Nutr. 1991;54(4):642-8.

Implementation Processes to Deliver Integrated Programs

Borrelli B, Sepinwall D, Ernst D, et al. A new tool to assess treatment fidelity and evaluation of treatment fidelity across 10 years of health behavior research. J Consult Clin Psychol. 2005;73(5):852-60.

Kariger P, Frongillo EA, Engle P, et al. Indicators of family care for development for use in multicountry surveys. J Health Popul Nutr. 2012;30(4):472-86.

Economic perspectives

Paxson C, Schady N. Cognitive development among young children in Ecuador: the roles of wealth, health and parenting. J Hum Resources. 2007;42(1):49-84.

Measures and indicators for assessing impact

Bradley RH, Caldwell BM. The relation of infants' home environments to achievement test performance in first grade: a follow-up study. Child Dev. 1984;55(3):803-9.

Frith AL, Naved RT, Ekström EC, et al. Micronutrient supplementation affects maternal-infant feeding interactions and maternal distress in Bangladesh. Am J Clin Nutr. 2009;90(1):141-8.

Formative research methods

Black MM, Aboud FE. Responsive feeding is embedded in a theoretical framework of responsive parenting. J Nutr. 2011;141(3):490-4.

Engle PL, Bentley M, Pelto G. The role of care in nutrition programs: current research and a research agenda. Proc Nutr Soc. 2000;59(1):25-35.

Jin X, Sun Y, Jiang F, et al. "Care for Development" intervention in rural China: a prospective follow-up study. J Dev Behav Pediatr. 2007;28(3):213-8.

Modell B, Berry RJ, Boyle CA, et al. Global regional and national causes of child mortality. Lancet. 2012;380(9853):1556.

Walker SP, Wachs TD, Gardner JM, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007;369(9556):145-57.

Leveraging families' strengths, paraprofessional, and bundled services

Aubel J. The role and influence of grandmothers on child nutrition: culturally designated advisors and caregivers. Matern Child Nutr. 2012;8(1):19-35.

Claeson M, Waldman RJ. The evolution of child health programs in developing countries: from targeting diseases to targeting people. Bull World Health Organ. 2000;78(10):1234-45.

Horton R. Women's and children's health: no time for complacency. Lancet. 2012;380(9848):1123-5.

Krieger N. Proximal, distal, and the politics of causation: what's level got to do with it? Am J Public Health. 2008;98(2):221-30.

Madhavan S, Townsend N. The social context of children's nutritional status in rural South Africa. Scand J Public Health Suppl. 2007;69:107-17.

Målqvist M, Lincetto O, Du NH, et al. Maternal health care utilization in Vietnam: increasing ethnic inequity. Bull World Health Organ. 2013;91(4):254-61.

Olds D, Henderson CR Jr, Cole R, et al. Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA. 1998;280(14):1238-44.

Rahman A, Patel V, Maselko J, Kirkwood B. The neglected 'm' in MCH programs—why mental health of mothers is important for child nutrition. Trop Med Int Health. 2008;13(4):579-83.

Rotheram-Borus MJ, Swendeman D, Chovnick G. The past, present, and future of HIV prevention: integrating behavioral, biomedical, and structural intervention strategies for the next generation of HIV prevention. Annu Rev Clin Psychol. 2009;5:143-67.

Spoth R, Redmond C. Parent motivation to enroll in parenting skills programs: a model of family context and health belief predictors. J Fam Psychol. 1995;9(3):294-310.

Spoth R, Redmond C, Shin C. Modeling factors influencing enrollment in family-focused preventive intervention research. Prev Sci. 2000;1(4):213-25.

Tomlinson M. Family-centered HIV interventions: lessons from the field of parental depression. J Int AIDS Soc. 2010;13 Suppl 2:S9.

Wachs TD. Models linking nutritional deficiencies to maternal and child mental health. Am J Clin Nutr. 2009;89(3):935S-939S.

Walders N, Drotar D, Kercsmar C. The allocation of family responsibility for asthma management tasks in African-American adolescents. J Asthma. 2000;37(1):89-99.

The World Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. 2008.

Understanding care for early stimulation and feeding practices

Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed.: Jossey-Bass; 2008.

The Johns Hopkins University Center for Communication Programs. Health Communication Partnership. 2002–2007.

Parvanta C, Nelson DE, Parvanta SA, Harner RN. Essentials of Public Health Communication. Sudbury, MA: Jones & Bartlett Learning; 2010.

Integrating water, sanitation, and hygiene (WASH)

Dewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr. 2008;4 Suppl 1:24-85.

Maternal and child nutrition. Lancet. 2008.

Ruel MT, Menon P. Child feeding practices are associated with child nutritional status in Latin America: innovative uses of the demographic and health surveys. J Nutr. 2002;132(6):1180-7.

Shrimpton R, Victora CG, de Onis M, et al. Worldwide timing of growth faltering: implications for nutritional interventions. Pediatrics. 2001;107(5):E75.

Integration of a scalable maternal psychosocial well-being component

Rahman A, Malik A, Sikander S, et al. Cognitive behavior therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomized controlled trial. Lancet. 2008;372(9642):902-9.

Cross-national analyses of governance

Bradley EH, Fennell ML, Pallas SW, et al. Health services research and global health. Health Serv Res. 2011;46(6pt2):2019-28.

Britto PR, Yoshikawa H, Boller K. Quality of early childhood development programs in global contexts: rationale for investment, conceptual framework and implications for equity. Social Policy Report. 2011;25(2).

Engle PL, Rao N, Petrovic O. Situational analysis of young children in a changing world. In: Britto PR, Engle PL, Super CM, eds. Handbook of Early Childhood Development Research and Its Impact on Global Policy. New York, NY: Oxford University Press; 2013.

Kaufmann D, Kraay A, Mastruzzi M. Governance Matters III: governance indicators for 1996, 1998, 2000, and 2002. World Bank Economic Review. World Bank Group. 2004;18(2):253-287.

Yoshikawa H, Rosman EA, Hsueh J. Resolving paradoxical criteria for the expansion and replication of early childhood care and education programs. Early Childhood Research Quarterly. 2002;17:3-27.

Pérez-Escamilla R. Acculturation, nutrition, and health disparities in Latinos. Am J Clin Nutr. 2011;93(5):1163S-7S.

Advantages and disadvantages of integration

Integrating early childhood development (ECD) activities into nutrition programmes in emergencies. Why, what and how. WHO–UNICEF. 2012.

Hermann K., Van Damme W, Pariyo GW, et al. Community health workers for ART in sub-Saharan Africa: learning from experience — capitalizing on new opportunities. Hum Resour Health. 2009;7:31.

Webb P. Malnutrition in emergencies: the framing of nutrition concerns in the humanitarian appeals process, 1992 to 2009. Food Nutr Bull. 2009;30(4):379-89.

Integrating ECD and health and nutrition services in Bangladesh

Aboud FE, Akhter S. A cluster-randomized evaluation of a responsive stimulation and feeding intervention in Bangladesh. Pediatrics. 2011;127:e1191-7.

Aboud FE, Moore AC, Akhter S. Effectiveness of a community-based responsive feeding programme in rural Bangladesh: a cluster randomized field trial. Matern Child Nutr. 2008;4:275-86.

Aboud FE, Shafique S, Akhter S. A responsive feeding intervention increases children's self-feeding and maternal responsiveness but not weight gain. J Nutr. 2009;139:1738-43.

Hamadani JD, Huda SN, Khatun F, Grantham-McGregor SM. Psychosocial stimulation improves the development of undernourished children in rural Bangladesh. J Nutr. 2006;136(10):2645-52.

Nahar B, Hamadani JD, Ahmed T, et al. Effects of psychosocial stimulation on growth and development of severely malnourished children in a nutrition unit in Bangladesh. Eur J Clin Nutr. 2009;63(6):725-31.

Nahar B, Hossain MI, Hamadani JD, et al. Effects of a community-based approach of food and psychosocial stimulation on growth and development of severely malnourished children in Bangladesh: a randomized trial. Eur J Clin Nutr. 2012;66(6):701-9.

Nahar B, Hossain MI, Hamadani JD, et al. Effects of psychosocial stimulation on improving home environment and child-rearing practices: results from a community-based trial among severely malnourished children in Bangladesh. BMC Public Health. 2012;12:622.

Capacity building for interventions in the health sector

Campbell PH, Sawyer LB. Changing early intervention providers' home visiting skills through participation in professional development. Topics in Early Childhood Special Education. 2009;28:219-234.

De Onis M, Onyango A, Borghi E, et al. Multicentre Growth Reference Study Group. WHO Worldwide implementation of the WHO Child Growth Standards. Public Health Nutr. 2012;15(9):1603-10.

Ertem IO, Atay G, Bingoler BE, et al. Promoting child development at sick-child visits: a controlled trial. Pediatrics. 2006;118:e124-31.

Gilroy KE, Winch P. Management of sick children by community health workers. Intervention models and programme examples. WHO–UNICEF. 2006.

Kokanovic R, Furler J, May C, et al. The politics of conducting research on depression in a cross-cultural context. Qual Health Res. 2009;19:708-17.

Lehmann U, Sanders D. Community health workers: what do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. WHO. 2007.

Rakha MA, Abdelmoneim AN, Farhoud S, et al. Does implementation of the IMCI strategy have an impact on child mortality? A retrospective analysis of routine data from Egypt. BMJ Open. 2013;3(1).

Rowe AK, de Savigny D, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet. 2005;366:1026-35.

Cost-effectiveness of interventions in the PEDS trial

Karoly L, Killburn MR, Cannon J. Proven benefits of early childhood interventions. RAND Corporation. 2005.

Levin HM, McEwan PJ. Cost-effectiveness Analysis: Methods and Applications. 2nd ed. Thousand Oaks, Ca: SAGE Publications, Inc; 2000.

Rationale, design, methodology, and sample characteristics for Project Grow Smart

Bronfenbrenner U, Ceci SJ. Nature-nurture reconceptualized in developmental perspective: a bioecological model. Psychol Rev. 1994;101:568-86.

Sameroff A, ed. The Transactional Model of Development: How Children and Contexts Shape Each Other. Washington, DC: American Psychological Association; 2009.

Vazir S, Engle P, Balakrishna N, et al. Cluster-randomized trial on complementary and responsive feeding education to caregivers found improved dietary intake, growth and development among rural Indian toddlers. Matern Child Nutr. 2013;9:99-117.

Yousafzai AK. Quality of early child care and development programme: perspective from Pakistan. Presented at: Beyond Child Indicators: A Framework to Assess and Evaluate the Quality of Early Childhood Services and Programs in Global Contexts. NYU Abu Dhabi Institute. 2010.

Effects of micronutrient provisions in PANIN III beneficiaries

Schady N, Behrman J, Caridad Araujo M, et al. Wealth gradients in early childhood cognitive development in five Latin American countries. Presented at: Promises for Preschoolers: Early Childhood Development and Human Capital Accumulation. University College London. 2012.

Advancing the nutrition and ECD policy agenda

Morris SS, Cogill B, Uauy R. Maternal and Child Undernutrition Study Group. Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress? Lancet. 2008;371:608-21.

Pelletier DL, Frongillo EA, Gervais S, et al. Nutrition agenda setting, policy formulation and implementation: lessons from the Mainstreaming Nutrition Initiative. Health Policy Plan. 2012;27:19-31.

Pelletier DL, Menon P, Ngo T, et al. The nutrition policy process: the role of strategic capacity in advancing national nutrition agendas. Food Nutr Bull. 2011;32(2 Suppl):S59-69.

Websites

Care for Child Development

The Consultative Group on Early Childhood Development

Global Child Development Group

Improving Mother/Child Interaction to Promote Psychosocial Development

The Jamaica Curriculum

Learning Through Play

Mainstreaming Nutrition Initiative, ICCDR,B

World Bank — World Development Indicators

Sponsors

Presented by

Speaker:
Maureen M. Black, University of Maryland

According to the World Health Organization, 24% of children under the age of five—165 million children—do not reach their full developmental potential as a result of chronic undernutrition, a lack of developmental and educational opportunities, and high social and environmental risks. Maureen M. Black from the University of Maryland opened the meeting by comparing the normal trajectory of child development to stunting and discussed interventions that target nutrition and early childhood development (ECD).

In optimal conditions for development, protective factors outweigh risks. That ratio changes as the stress burden on a child increases. Interventions can improve this ratio but cannot fully normalize it. (Image courtesy of Maureen M. Black)

Stunting has a huge economic cost, not just for individuals but also for countries. Recent estimates suggest that over 10% of gross national product is lost in developing countries as a result of poor nutrition. Child development involves an orderly progression of skills; the first 1000 days of a child's life, from conception to age two, are crucial for normal neurological development (such as myelination and synaptogenesis) and functional development (such as language skills and sensory development). Some disparities that cause stunting are already present at birth, so the first 1000 days are especially important for interventions.

Association studies have demonstrated that extreme wasting and stunting are both linked with poor development outcomes, but randomized controlled trials show a less clear relationship. Long-term follow-up suggests that positive outcomes often fade over time, but some studies have found evidence for synergistic benefits when nutritional interventions are combined with interventions that involve cognitive and emotional stimulation.

There are many open questions. What is the optimal time to intervene? Can late interventions correct cognitive and other effects of early stunting? How do social factors such as poverty, institutionalization, and lack of caregiver responsiveness affect early brain development? Do nurturing parents provide a buffer against prenatal and early postnatal stressors? Black posited that answering these questions will require models that are complex enough to include a broad array of possibilities from different disciplines.

Studies suggest that interventions should start early to prepare children for school and continue though childhood. Children with low cognitive skills need earlier interventions, while those doing well benefit from later investment. Disparities present at age five persist through age 18, and there are large disparities in preschool availability for low-income children. Government investment in child development varies dramatically across the world.

Nutritional and ECD interventions have overlapping goals and are targeted to the same period in development, so delivery through a shared infrastructure could improve efficiency and streamline messaging to families. However, integrating across health and education sectors can be difficult, and too much information provided at one time can be overwhelming for service providers and caregivers. At this meeting, researchers delved into issues such as the optimal timing, duration, and intensity of interventions; the training health workers need to deliver two types of interventions at once; how to measure outcomes; the effectiveness of government policies; and the sustainability and scale of ECD programs.

Speakers:
Theodore D. Wachs, Purdue University
Sally Grantham-McGregor, University College London, UK
Aisha K. Yousafzai, Aga Khan University, Pakistan

Highlights

• Nutritional interventions are most effective in early in childhood or prenatally, but other interventions can be targeted to later ages.
• There is an urgent need to evaluate the efficacy of intervention programs at scale and to determine how to measure child-development outcomes.
• Intervention programs must improve reporting on the implementation process so that researchers can understand which elements are effective.

Timing early interventions

What is the best time to intervene to influence development? Theodore D. Wachs from Purdue University reviewed evidence from nutrition science, neuroscience, and developmental psychology that points to particularly sensitive time windows when interventions are most successful.

Data suggest that interventions targeting nutrition are effective at early ages; for example, children are at the highest risk for iron deficiencies before they reach age two. But non-nutritional factors such as hormonal growth factors, stress, and maternal health status are also at play at this time. Stress at low levels can facilitate development, but high-intensity, cumulative "toxic" stress can lead to aberrant brain architecture and physiological changes.

Brain development continues well past age two, and evidence suggests that aspects such as memory, cognition, peer socialization, and self-regulation continue to evolve in adolescence and young adulthood. Studies show that later interventions can improve cognitive, academic, and emotional development, which appear to have a wider window for intervention, extending past early childhood into school age. Thus, the critical question for these other interventions is not necessarily when to start, but which functions to target, Wachs concluded.

Combining child-development interventions with nutritional or health interventions

Children at risk for poor health and nutrition are generally also at risk for underdevelopment. Sally Grantham-McGregor from University College London reviewed trials that measured the efficacy of different interventions in low- and middle-income countries in order to determine whether targeting multiple elements at once produces synergistic effects. Out of 1659 studies in the literature, she and her colleagues identified just 14 efficacy trials and eight program evaluations for health, nutrition, and stimulation interventions that met their criteria.

Of the 14 efficacy trials, six were randomized controlled trials (RCTs), and in these, stimulation—alone and combined with nutritional or health interventions—consistently improved development. Nutritional supplementation improved development in half the studies and improved growth in most. There was little evidence of synergistic effects, although the data were limited. In the non-RCT efficacy trials, stimulation improved development but results for growth and nutrition were mixed.

The eight program evaluations found no robust evidence to support integrating child-development programs into health services at scale. Some programs were beneficial, but others were found to be harmful, and there was no evidence of sustained effects. Thus, the claim that any kind of intervention is better than none is inaccurate.

Grantham-McGregor said there is, therefore, an urgent need for long-term studies to evaluate program efficacy. It is crucial for nutrition scientists to think more about how to measure child development at scale and about why the nutritional components of the programs are not working. Searching for alternative models to deliver services, beyond simply using existing structures in the health care system, is also important.

Integrating nutritional interventions and psychosocial stimulation

Five features for evaluating whether the fidelity of an intervention has been maintained during implementation. (Image courtesy of Aisha K. Yousafzai)

Researchers have a poor understanding of how implementation processes affect the outcome of an intervention. Aisha K. Yousafzai from Aga Khan University emphasized that evaluations should consider program fidelity: how well a program conformed to its stated plan, which features made it more or less successful, and how intensive it had to be to produce long-term results.

In a review of the literature, Yousafzai and her co-author identified 26 studies in the Ovid database that described interventions combining nutrition and psychosocial stimulation in children up to five years old in low- and middle-income countries. The review evaluated the interventions based on their context, intensity, and content; the background and training of personnel delivering the interventions; and the supervision these individuals received. But it revealed little about what determines program success and there were scant details about the training and supervision service providers received.
 

Yousafzai recommended that time and resources be dedicated to evaluation, and said more studies should look at the association between the implementation process and child development and growth.

Discussion

Audience members and speakers noted the disparity between intervention-efficacy studies and what is actually feasible on the ground. A study might find that spending 30 to 60 minutes with a client is beneficial, but this may not be possible. Some commented that the integrity of an intervention might depend on whether the community takes ownership of its delivery, but others noted that the effectiveness of local efforts is sometimes questionable.

Another theme of the discussion was the rationale for targeting interventions to the first 1000 days of life (prenatal to age two). While all agreed that this early period is extremely important, many noted that cognitive or behavioral outcomes—and even some nutritional ones, such as obesity—would be more appropriately addressed in later years. Studies are needed to examine how factors such as children's nutritional status and mothers' education level affect the impact of interventions.

Speakers:
Harold Alderman, International Food Policy Research Institute
Edward A. Frongillo, University of South Carolina
Margaret E. Bentley, University of North Carolina

Highlights

• More research is needed to evaluate the cost of changing behavior.
• More research is needed to validate measures of child development.
• There is a lack of guidelines on conducting formative research.

Economic perspectives

The optimal timing for nutritional intervention is relatively well documented: it should occur before the child is two years old. But the timing for delivery of other types of developmental stimulation might be later, and it is not clear how to integrate such interventions into nutritional programs or how to determine the economic benefits of doing so, said Harold Alderman from the International Food Policy Research Institute.

Providing developmental stimulation to malnourished children can partially close the cognitive gap, but no known set of interventions works preventatively at scale. The few existing effective programs are extremely resource-intensive, both for service providers and for the mother or caregiver, and are therefore difficult to scale up.

Alderman noted that even if the timing of different interventions is not simultaneous, it is possible to create continuity—what he called "programmatic synergy"—by building upon an early bond created between the service provider and the target household. The positive effect of nutritional interventions on cognitive capacity is well known, as is the link between better schooling and improved wages. He advocated tracking this chain of events more closely and documenting the financial cost of changing behavior.

Assessing impact: nutritional and ECD interventions

Edward A. Frongillo from the University of South Carolina identified four domains that interventions might affect—food and nutrition, family care, health, and child development—and emphasized that studies evaluating interventions should assess impacts in a consistent manner. He and his colleagues reviewed commonly-used measures and indicators to assess the validity, sensitivity, and feasibility of these studies in different contexts.

The researchers identified multiple measures and scales that could assess interventions, such as the Household Food Insecurity Access Scale. But few measures of child development have been validated—even those that are widely used. Frongillo said that the field must address this deficit with further research. Other measures are difficult to use. The Bayley Scales of Infant Development, a common measure, requires special training, and many field researchers have expressed a desire for a less-technical alternative.

Designing culturally appropriate integrated interventions

Formative research should be conducted to inform project design before an intervention is launched, but papers that describe integrated interventions often give little to no information about this research, or whether the project implemented a novel intervention or adapted a pre-existing one to a specific environment or cultural context, said Margaret E. Bentley from the University of North Carolina.

Formative research generally involves a combination of individual interviews, observations, and focus group interviews. (Image courtesy of Margaret E. Bentley)

Formative research can include one-on-one interviews assessing individual-level knowledge, attitudes, and beliefs; direct observation, which should ideally be video recorded; and focus-group interviews assessing cultural and social norms that affect target behavior. Specific questions about feeding, development, and household and community roles can inform project design. Bentley stressed the importance of considering children's age and gender, maternal education and autonomy, food availability, and the inclusion of other caregivers (father, grandmother) and community leaders in the study.

Bentley described a case study of formative research for an integrated feeding and care intervention in rural India. The team identified opportunities for behavioral change, developed the intervention messages, and defined measures to assess efficacy. She noted that they found a significant lack of guidelines on formative research, particularly in the field of child development.

Discussion

The discussion focused on study design, such as which measures of child development could realistically be used at scale, and how to evaluate efficacy. Feedback from caregivers is often unreliable; for example, mothers' answers can be biased by preconceptions about the correct response to a question.

The timing of interventions is important. In studies that follow children through development, it is not always clear when to measure progress. Another concern, noted throughout the meeting, was whether some programs deliver too many messages at once, overwhelming caregivers' ability to receive information and health care workers' ability to deliver it.

Speakers:
Mark Tomlinson, Stellenbosch University, South Africa
Raghu Lingam, London School of Health and Tropical Medicine, UK
Rebecca J. Stoltzfus, Cornell University
Atif Rahman, University of Liverpool, UK
Pia Rebello Britto, Yale Child Study Center

Highlights

• Nutritional and child-development interventions must be extended to the poorest families, which are often left out of such services.
• Researchers must understand local beliefs, customs, and practices in order to design effective interventions.
• Hygiene and sanitation play an important role in ECD, but interventions in this domain are not as well developed or well tested as interventions in nutrition, stimulation, or social protection.
• Health workers delivering child health, nutritional, and developmental interventions could also be trained to address basic aspects of maternal-psychosocial and mental health.
• The most local level of government could serve as an entry point for efforts to improve child-development services.

Leveraging families' strengths, paraprofessionals, and bundled services

Interventions are not distributed equally, according to Mark Tomlinson from Stellenbosch University. Although mortality in children under age five has dropped globally since 1990, it has increased in 13 countries, and newborn deaths have increased in 26 countries. Extending existing child-development interventions to the poorest children, who are often left out, is essential.

Japanese dairy cows receive more financial investment annually than do people living in 63 low-income countries. (Image courtesy of Mark Tomlinson)

There are many barriers to participation in interventions, including dispersed families and migration; family beliefs; resistance from fathers and grandmothers, who can act as gatekeepers to mothers' participation; maternal health problems, such as depression or HIV status; and cost, lack of transportation, and poor infrastructure. Overcoming these barriers requires tailoring interventions to particular communities. For example, targeting interventions solely to mothers is ineffective in areas where children are left with their grandmothers for extended periods. Tomlinson described a study in which his team used motivational interviewing to convince HIV-positive mothers to breastfeed and then talked through barriers that might prevent them from implementing their decision.

Increasing participation in interventions will involve a combination of center-based and home-based programs, and the frequency and quality of contact between community health workers and participants may need to be improved. Integrating interventions and increasing coverage will also be crucial; an inoculation model in which only a single intervention is delivered will not work.

Understanding care and feeding practices: building blocks for a sustainable intervention

Raghu Lingam from London School of Health and Tropical Medicine described his team's formative research for a package of interventions in rural India and Pakistan called SPRING. The interventions, delivered through community-based agents, aimed to maximize child development, growth, and survival and improve maternal psychosocial well-being.

The research aimed to determine how local beliefs and practices would influence the success of these interventions and to identify ways to integrate them into existing activities and scale-up, if effective. Over a year, the researchers interviewed family members and directly observed mothers interacting with children. They identified parental aspirations for their children and practices relating to feeding, weaning, and play as important.

They explored who would receive the interventions, which behaviors would be targeted (for example, exclusive breastfeeding from age 0–6 months old), what the potential benefits would be, which barriers might prevent participation, and how interventions would be delivered.

A matrix describing formative research for the SPRING project. (Image courtesy of Raghu Lingam)

Integrating water, sanitation, and hygiene with a nutritional intervention

The extent to which diarrhea affects child growth is controversial, but one longitudinal study in Peru reported that 40% of the height deficit at age two could be explained by sanitation conditions in the child's household. Rebecca J. Stoltzfus from Cornell University described her team's work to determine whether preventing a subclinical small-intestine condition called environmental enteropathy (EE) would reduce stunting. They developed an intervention in rural Zimbabwe that aimed to prevent babies under 18 months old from ingesting animal and human feces.

While conducting formative research, the group found that children most frequently develop EE after ingesting dirt and chicken feces, which contains 10 million E. coli cells per "serving," while playing on the kitchen floor. They initially proposed to create a protective play space for babies, but found that this is culturally unacceptable because it contradicts a belief that exploration is integral to healthy development. The team is still exploring this possibility, but is also testing a hygiene intervention that encourages infant hand washing and other sanitation efforts.

Many early-childhood programs provide nutrition, stimulation, and social protection, but hygiene programs are less common and not as well understood. Stoltzfus's group is comparing their hygiene intervention with an infant-feeding and education intervention to measure the independent and combined effects of multiple interventions on stunting and anemia in children under 18 months old.

Integrating maternal psychosocial well-being into child-development interventions

Early-childhood interventions tend to be delivered through the mother. Atif Rahman from the University of Liverpool discussed the SPRING interventions in India and Pakistan described by Raghu Lingam, focusing on a component that aims to support maternal well-being. Up to 25% of women in the developing world suffer from depression, which studies suggest is associated with poor outcomes for children.

Four years ago, Rahman's group trained SPRING lady health workers (LHWs) in rural Pakistan to address mothers' mental health. They taught the LHWs how to integrate new elements into a nutritional/ECD intervention, including family support, empathetic listening, challenging beliefs using pictures, encouraging mothers to take small steps toward improvements (behavioral activation), and encouraging problem solving. Pilot evaluations of the enhanced intervention observed the work and collected feedback from the LHWs and mothers.

Health workers had to adapt to spending more time listening to mothers than delivering instructions. In most cases, both parties found the interaction more satisfying: health workers were able to engage more family members, and mothers felt better supported. The team is planning further research to assess this approach and is working with local partners to ensure that it is scalable.

Discussion

Audience members asked whether the psychosocial intervention Rahman described could more directly address domestic violence and women's empowerment. Rahman said his team did not do so because that would likely raise intense resistance. Instead, he said, the intervention addressed these issues indirectly by encouraging family dynamics to change. He also said that the group plans to assess the sustainability of the intervention and suggested that researchers should work with local stakeholders to plan how to scale up interventions from the outset.

Another challenge that was raised is researchers' ability to look past their assumptions and recognize their limited knowledge of local culture. Lingham and Stoltzfus noted that formative research could help identify problems with a planned intervention in advance. They also said that understanding culture is an iterative process that should continue throughout each project.

Understanding how to scale up early-childhood interventions in the context of governance

Early-childhood services are not often implemented through a designated government system, but through a patchwork of local and national institutions (such as the health and education sectors) and non-governmental organizations. Pia Rebello Britto from Yale Child Study Center reported that these services are becoming more popular. Her team examined how local, regional, and global governance impacts how ECD programs are run and scaled up.

The research examined the policy infrastructure for early-childhood programs in two countries in East Asia, two in east and southern Africa, and two in Latin America. Within each country, they interviewed individuals at different levels of the government hierarchy and in different geographical areas—the capital (generally the wealthiest district), a median-performing region, and a particularly poor region. People at different levels of government had very different ideas about what a "quality" program is, Britto said.

The researchers mapped the policy architecture for several countries in East Asia, east and southern Africa, and Latin America. This graphic shows the policy-architecture map for Kenya. (Image courtesy of Pia Rebello Britto)

The research also looked at the policy architecture in each country—the documents that guide early-childhood interventions. A key aspect of implementing integrated nutritional and ECD interventions is establishing collaboration between the health ministry and the education ministry; in Laos, for example, the former is very hierarchical while the latter is not, and the discrepancy makes integration more difficult.

In each country, local governments were most concerned about effective service delivery. This level of government could therefore serve as an entry point for improving access to services and scaling up interventions.

Speakers:
Ann DiGirolamo, CARE International
Jena Derakhshani Hamadani, International Center for Diarrheal Diseases, Bangladesh
Aisha K. Yousafzai, Aga Khan University, Pakistan
John Phuka, University of Malawi, Malawi

Highlights

• Integrating nutrition and ECD services has many benefits, but there are also challenges.
• In Bangladesh, ECD programs need to be better integrated into existing health services and need more stringent evaluation.
• To increase the capacity of ECD service providers, health workers should be trained to support behavioral change.
• Malawi must strengthen its infrastructure to achieve its policy goal to expand ECD services.

Advantages and disadvantages of integration

Researchers recognize the benefits of early interventions to address children's nutritional and developmental needs, but resources are limited. Ann DiGirolamo from CARE International emphasized that it is important to consider both the opportunities and the challenges posed by integrating nutritional and ECD services.

Integration can be cost-effective and may simplify service delivery for both health workers and caregivers; for example, coordinated messaging may be easier to grasp and can provide a framework for more holistic services. However, integrated services may also increase the workload for health workers and require more supervision and monitoring by program supervisors. In addition, integration relies on collaboration between two disparate fields, as well as between sectors and ministries of government that do not interact with each other often.

Addressing these challenges requires creating multifaceted resources—from incentives and job descriptions for health workers to simpler, integrated measurement tools—and continued research. DiGirolamo suggested that emergencies and conflict situations can provide opportunities to introduce integrated nutrition and ECD programming, particularly if agencies on the ground in such situations value integration

Integrating ECD programs into health and nutrition services in Bangladesh

More than 300 non-governmental organizations are implementing ECD programs in Bangladesh, but few include nutrition programs. Jena Derakhshani Hamadani from the International Center for Diarrheal Diseases in Bangladesh reviewed data from four program evaluations and seven efficacy trials for integrated interventions.

ECD programs are supported by the government, but have not been conducted regularly, Hamadani said. A network of community clinics established about ten years ago that ceased operations during a change in government has now restarted. But most programs target preschool-age children and few offer parenting guidance, provide intervention for children under age three, or integrate nutrition and ECD. Efficacy trials examined interventions for children under age three and reported benefits in several measures. Hamadani and her colleagues followed up on a trial they published in 2006, which provided psychosocial stimulation to malnourished children aged 6–24 months, and found that by ages 9 to 11 the benefits of the original intervention had largely faded.

Now that the government has prioritized ECD, such programs must be integrated into existing health and nutrition infrastructure. Hamadani noted that very few programs are based on research findings and even fewer have been evaluated.

Capacity building for improving child development and nutrition in the health sector

Health workers are usually adept at providing injections, pills, and micronutrients, but not at promoting and supporting behavioral changes, said Aisha K. Yousafzai. She recommended training providers to take ownership of programs so that they can respond to the needs clients identify, rather than relying on a scripted visit schedule. The goal of this training should be to impart knowledge that can be used in real-life settings. Knowledge mobilization must also occur at the policy level.

ECD must be supported at multiple levels to be effective. (Image courtesy of Aisha K. Yousafzai)

Through its 13-week training program for managers, field staff, researchers, teachers, doctors, and nurses, the Aga Khan Development Network has increased awareness of ECD and plans to develop short courses for a wider audience, such as health education agencies. The course uses an international version of a five-module online resource developed by researchers at the University of Toronto called the Science of Early Child Development. Yousafzai suggested that ECD training should be provided to graduating doctors and nurses and offered through professional organizations. She also described other training schemes that could help build capacity for ECD, such as the World Health Organization's Care for Child Development and Integrated Management of Childhood Illness programs.

A job analysis of community health workers providing integrated services

The Malawian government plans to expand access to child-development services from 30% to 62% of children under age five. John Phuka from the University of Malawi and his colleagues studied the role community health workers could play in integrating services for child nutrition, health, and psychosocial development.

Health workers receive up to 12 weeks of training funded by the government, plus refresher courses. The curriculum currently contains no ECD, but health workers expressed interest in including it. Each health worker serves 1000 to 5000 people, and although most reported feeling overworked, they also indicated they could take on additional projects. Child protection workers are less numerous (there is one per 6000 to 25 000 people) and not as widely recognized in communities, but they also expressed interest in integrating ECD into their projects. Among caregivers, there was little sense of ownership of the services these health workers provide. According to Phuka, although Malawi has a policy goal to expand ECD programs, scaling up services will be challenging because of a lack of resources.

Discussion

The discussion focused on the difficulties of making integrated programs operational. DiGirolamo said that rather than focusing on technical expertise in distinct modalities, such as nutrition or education, we should consider how different sectors affect one another. Phuka suggested that researchers should step back from overspecialization and think about interventions more broadly, from a public health point of view. The discussion also touched on the conflicting agendas that different stakeholders can have for health workers delivering a range of interventions.

Gaps in the science of implementation were also addressed. One participant asked whether trial designs other than randomized controlled trials would be helpful for evaluating different components of intervention programs. Yousafzai noted that although programs exist in South Asia many are not implemented effectively. Grantham-McGregor concluded the discussion by pointing out that no evaluation data exist for scaling up interventions. Furthermore, researchers have not agreed upon good measures of ECD that could be submitted to ministries of finance to gauge a program's success and request continued funding.

Speakers:
Saima Gowani, Columbia University
Kirsten M. Hurley, Johns Hopkins School of Public Health
Florencia Lopez Boo, Inter-American Development Bank

Highlights

• Integrating responsive stimulation into a rural health program in Pakistan is cost-effective, according to an analysis of 1500 children.
• Studying the impact of integrating a micronutrient intervention with a play and communication intervention is a time-intensive, multiphase process.
• A nutritional supplementation program in Nicaragua is cost-effective, but does not improve child-development outcomes.

Cost effectiveness of responsive stimulation and nutrition intervention in rural Pakistan

Research on the cost effectiveness of interventions in children under three years old is scarce. Saima Gowani from Columbia University presented an economic analysis of the Pakistan Early Childhood Development Scale Up (PEDS) trial, a randomized comparison of child-development outcomes after an enhanced nutritional intervention, a responsive-stimulation intervention, and an intervention combining the two. Services were delivered by LHWs in monthly home or group visits to 1500 children age 0–2 years old, and participants were followed for two years.

The researchers first calculated the cost of each intervention and found that responsive stimulation was the most expensive, at $4 per child per month. The integrated group had the best outcomes for cognitive, motor, and language development. The integrated intervention was the most cost-effective in the first year of the study, but responsive stimulation alone was most cost-effective in the second year.

Calculating the cost per month in local currency for a one-point gain on the Bayley scales might provide data to convince policy makers to fund the service. Gowani suggested that the long-term effects of interventions on factors such as school performance or wages could yield convincing cost–benefit data.

Rationale, design, methodology, and sample characteristics for an integrated program in rural India

Kirstin M. Hurley from Johns Hopkins School of Public Health described a randomized study that evaluated the impact of an integrated program combining a micronutrient intervention with a play and communication intervention. For infants in the study (6–24 months old), health workers delivered one of four interventions including play/communication and micronutrient supplementation in biweekly home visits.

Preparing the study was a time-intensive, multi-phase process. In a preliminary phase, the researchers obtained approvals from government and local oversight bodies and developed the interventions; a preparatory phase involved formative research; a formative phase involved a pilot test of a micronutrient sachet and a feasibility assessment of the play and communication intervention; and a final phase involved training health workers in data collection.

Back and front of a card used to prompt a play intervention in rural India. (Image courtesy of Kirstin M. Hurley)

Developing the micronutrient sachet was especially challenging, Hurley said. It had to be deemed acceptable in terms of smell, color, and taste. Caregivers were taught how to mix it into food and advised not to share it with other children in the household. Mothers expressed concern about where to store the sachets, so the researchers also developed special storage bags. For the play and communication intervention, health workers showed mothers cards with pictures demonstrating a behavior, such as playing peekaboo. The study required continuous monitoring and supervision of health workers delivering the intervention.

The cost and benefit of micronutrient supplementation in Nicaragua

In Nicaragua 22% of children under age five suffer from chronic malnutrition and 30% of children under age three suffer from anemia. Florencia Lopez Boo from the Inter-American Development Bank presented data from a government program that provides micronutrient supplements within an integrated ECD intervention. The program showed a very small benefit for language and cognitive development, but did decrease anemia among participants, so she conducted a cost–benefit analysis to determine the monetary value of this impact.

The program, called PAININ, is delivered at government-sponsored day care centers (mostly urban) or at community centers run by volunteer mothers in their homes (mostly rural). Lopez Boo reported that it cost only $72 per child per year (or $42 when excluding food), which is extremely low by Latin American standards. For children under three years old, she calculated that receiving the nutritional intervention led to 0.22 more years of education and about seven months less delay in starting school. That translates to approximately 12% higher wages per year, she said, and for every dollar spent on this program, the potential gain for these children is $3–$6. Integrating micronutrient supplementation with an ECD program thus seems to be a cost-effective option.

Speakers:
David Pelletier, Cornell University
Oliver Petrovic, UNICEF
 
Moderators:
Susan Walker, University of the West Indies, Jamaica
Maureen M. Black, University of Maryland

Highlights

• UNICEF's MICS4 survey provides powerful data for understanding ECD at the population level and for identifying priorities for interventions.
• The World Bank's SABER database allows users to compare details of national-policy frameworks to identify how policies could be strengthened to improve ECD.

Advancing the nutrition and ECD agenda: indicators and guidance

Despite the known benefits of ECD and governments' interest in providing it, program outcomes are poor, indicating problems in the policy sector, said David Pelletier from Cornell University. He described a World Bank initiative to map national-policy measures relating to ECD for countries around the world. This is part of a larger project called SABER (Systems Approach for Better Education Results), which has already collected multisectoral data for 20 countries and will eventually be compiled in a public website that will compare national-policy frameworks.

Rubric developed by SABER to evaluate national-policy measures relating to ECD. (Image courtesy of David Pelletier)

The database evaluates three policy goals: establishing an environment that promotes ECD (or another sector), implementing programs widely, and monitoring and assuring quality. It will be able to identify areas of progress and areas that need improvement. To illustrate, Pelletier presented data from Colombia, the Kyrgyz Republic, and Tanzania—which have ECD programs SABER classifies as "established," "latent," and "emerging," respectively—that points to specific challenges for ECD policy. He then discussed data from another World Bank-funded project, the Mainstreaming Nutrition Initiative, which helped identify how countries might strengthen strategic capacity for ECD programs.

Panel discussion: scaling-up integrated interventions

In a panel discussion moderated by Susan Walker from the University of the West Indies, Pelletier said that the key initial step for successful scale-up is achieving cohesion within the policy community. Policy makers must find an "optimal level of precision or ambiguity around which they could agree." This probably excludes the specifics of resource allocation. One concern voiced by a participant was that it is not clear which elements of intervention programs are most effective, and thus the high-impact pieces might not be not scaled up—resulting in a program that has little or no impact.

Yousafzai noted that there is little data on which factors influence program effectiveness. Another concern is cost: the monitoring component of a program is likely to be cut when it is scaled up, but intervention programs require a lot of monitoring to ensure they are implemented well and that efficacy is not lost. Finances can scuttle success even before a program is ready for scale-up: projects are typically 3 to 5 years long, which means that, because of the typical length of grants, funding ends just as results being to appear. Current measures of success are also inadequate: scales like Bayley developmental scores are unlikely to convince governments to fund ECD projects. Participants proposed possible alternative—such as relating ECD to school performance—that could be linked to incentives like wasted school budgets or lost wages.

New evidence on ECD in developing countries

For 15 years UNICEF has run a periodical global index of child and maternal health called the Multiple Indicator Cluster Survey (MICS). The current fourth round of surveys (MICS4) is collecting data on 110 indicators of health, nutrition, child protection, education, and ECD in developing countries. Oliver Petrovic from UNICEF provided a glimpse of these new data.

The purpose of the index is not to rank countries, Petrovic said, but to view child development at the population level, look at how different types of investments are interrelated, and identify priorities for interventions. Because the data are disaggregated by multiple factors such as location, gender, education level, age, and income level, MICS is a powerful tool for monitoring disparities.

Countries like Serbia, with a high ECD index and a low level of inadequate care (which is measured by the frequency with which small children are left alone), are on target for child development. Countries like Mali, on the other hand, have low ECD index scores and high levels of inadequate care and are lagging behind in child development. (Image courtesy of Oliver Petrovic)

The data show, for example, that wealth-based disparities in access to ECD services are decreasing in countries like Mongolia, but remaining steady in other countries such as Sierra Leone. Well-designed measurement tools test hypotheses about the effects of adversity, Petrovic said. For example, in one data set, 12.5% of stunted children aged 3 to 5 years old were on track for literacy and numeracy while 33% of non-stunted children had these skills, providing evidence that could be used for advocacy.

Panel discussion: conclusions

Maureen M. Black, who moderated the final panel, began by asking panelists to offer advice to someone designing a program that is rigorous, acceptable to the local community, and addresses specific issues.

DiGirolamo stressed the need to start with a very strong analysis phase and to incorporate a reliable set of indicators, simple enough to be applied in different contexts. Rahman said it is crucial to work closely with local stakeholders to ensure that the program targets a problem that is important to the community. He said maternal mental health is a proxy indicator for many factors that can affect the success of an intervention, such as self-esteem and sense of empowerment in the community, and it can be addressed through many avenues, including child development.

Lingam noted that since many interventions are achieving little impact on the ground, assessing failures is as important as reporting successes. Frongillo pointed out the importance of resource realism—considering limitations on time and funding—and the need to indentify interventions that are feasible. He suggested that organizations should not pursue interventions that research has shown cannot be scaled.

Black noted that none of the interventions discussed at the meeting were truly integrated. Wachs said that conceiving of interventions in components like nutrition and psychosocial development does not lend itself to integration. Lingam suggested taking ECD out of the context of integration with nutrition and thinking of it instead as a part of child survival.

The terminology of the field may also need to be changed, said one audience member. The phrase chronic undernutrition implies that people should receive more calories, but the situation is much better reflected by the word stunting. Similarly, stimulation sounds like something a machine does; a better phrase might be reaching the child's potential.

At what ages are particular child-development interventions best targeted?

Do some types of interventions have synergistic effects when combined?

Can later interventions reverse the effects of early deprivation?

What measures should be used to evaluate the efficacy of ECD and nutritional intervention programs?

How can researchers best identify which elements of an intervention program are successful?

What are the economic costs of ECD interventions and how much return do they bring?

How should the delivery of multiple health- and development-related messages be balanced with the need to avoid overwhelming caregivers with information?

How can nutritional and ECD interventions be extended to the poorest families, which are often left out of such services?

How can interventions geared towards children also take into account maternal well-being?

How can government policy be optimized to improve child nutrition and welfare?

What kinds of training and supervision best support health workers delivering child nutrition and ECD interventions?