“The debate between nature-nurture… is over“, rightly established UNICEF Executive Director Anthony Lake and World Health Organization Director-General Dr. Margaret Chan in a new article of the The Lancet published last week.
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They mentioned that policies should take into account new developments in neuroscience and their main recommendations are:
- Interventions should focus on brain development in order to be effective and therefore should start early when brain plasticity is at its peak.
- Interventions should be intersectoral and provide services including health, nutrition, high-quality caregiving, and protection.
- Interventions should start before conception, taking into account the prenatal period and even women’s adolescence.
Here is the situation
In my humble opinion, most countries in the Latin American and Caribbean region, have already made or are making important efforts in terms of maternal health and girls’ healthy development (Salud Mesoamérica 2015 is a good example). However, the first two recommended policies, intersectoral actions and focus on brain development early in life, are very complex to translate into concrete, implementable actions.
What does it mean to take the brain into account on early childhood policies and programs? And how can intersectoral policies be usefully and successfully implemented? In the region, early child development services, particularly for children 0–3 years of age, are far less common than services aimed at children in the 4-6 age group. Incorporating early child development activities into the health system— through prenatal care, breastfeeding promotion programs, well-child visits, consultations for mild illnesses, parenting education, and early intervention for children at risk—might actually provide the best opportunities for reaching children younger than 3 years. However, the challenges of implementation are enormous and tackling them is comparable to facing a beast.
Searching for a solution
I believe the solution lies on developing innovative, low cost delivery platforms that are both feasible and effective at scale. In this context, and particularly for early psychosocial stimulation interventions, critical for brain development, we know that home visits are indeed really effective (See Jamaica post). However, one of the main issues is the cost of educators and supervisors to visit homes (pre-service and in-service training, mentoring, supervision, per diems for travel, among others) as well as the cost in time for the mothers who receive the visits on a regular basis. Recent literature (albeit not from the Region) shows that groups in combination with home visits may be beneficial. It would be also interesting to know the effectiveness of hybrid parenting program, such as child care programs that provide parenting support and therefore attract a large amount of “captive” population.
The Lancet comment as well as Pia Britto’s blog point out to the Care for Child Development UNICEF/WHO package (CCC), an intervention in which parents are given instructions on both nutrition and stimulation. This package has been widely used in our region under the name AIEPI. Patrick Premand wrote a post in our blog sharing the experience of applying this package in Africa. Although the proposal sounds very promising, there is still relatively little research on the effectiveness at scale of this type of packages or any other that integrates cross-sectorial delivery of early childhood services.
Last year, a study by Grantham Mc Gregor and other authors concluded that “… trials showed nutritional interventions usually benefited nutritional status and sometimes benefited child development. Stimulation consistently benefited child development. There was no significant loss of any effect when interventions were combined, but there was little evidence of synergistic interaction between nutrition and stimulation on child development. We found no rigorous evaluations of adding stimulation to health and nutrition services at scale and there is an urgent need for them.”
Results from a study in Pakistan on the evaluation of an adaptation of the UNICEF and WHO Care for Child Development package were released last June and found that responsive stimulation intervention can be delivered effectively by lady health workers and that they positively affect development outcomes. Although this sounds like good news, the absence of a major effect of the nutrition intervention on growth seems to show the need for further analysis that will help to better design and implement nutrition interventions (see Yousafzai and colleagues in the Lancet).
The brain so beautifully crafted
Synaptic connections in the brain are established by the interaction with the environment. When stimuli activate a neural pathway, all the synapses that comprise that pathway receive and store a chemical signal, and are strengthened by the repetition of that incoming signal. When the signal exceeds a certain threshold, that synapse is exempt from elimination. Similarly, synapses that are not sufficiently reinforced by stimuli will be removed. It is far better than a Stradivarius violin.
On the other hand, even beautifully designed early childhood development policies and programs seem to be facing important challenges of implementation, from training and adequately compensating staff to performing the right frequency and quality of monitoring and supervision. The CCC model and other similar integrated interventions are strategies with potential benefits to large number of children; the key to achieve the same perfection as the brain relays on paying close attention to the details of implementation. Only then, the symphony will be complete.
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