In March, the World Health Organization (WHO) released a 67-page document with guidelines to improve the development and well-being of children aged 0-to-3. Its conclusion: In order to support kids, we must support their caregivers, because their love and care is what children really need to thrive.
If this seems obvious, it’s because it is is. But it represents a revolution in how governments and organizations think about supporting the most vulnerable creatures on the planet: infants and toddlers. It marks a dramatic shift from focusing on what young children need in order to survive—calories and medicine—to the science which proves that, as much as food, they need consistent, warm, loving care. That means talking to them, even if we think they can’t understand; playing with them, even when we don’t see the point; and being gentle and present, as much as possible, and even in difficult circumstances, when it feels like they don’t notice.
The approach might sound “mushy.” But getting the world’s leading public health body to back guidelines supporting love and nurturing care was a feat of science and advocacy decades in the making. Supporters hope it will give poor countries, and even some richer ones, the push they need to actually invest in protecting and improving children’s early years.
When it comes to children and families, international aid has for decades mostly gone into two buckets: nutrition and health. A recent study found that, between 2007 and 2016, $79.1 billion of development assistance logged in the OECD’s Creditor Reporting System database was spent on the broad category of early childhood development (ECD). But 78% of it, or $61.9 billion, went to health and nutrition programs. Among other things, the new WHO guidelines could help convince donors that their money would be well-spent on more holistic programs that target children’s development and environment, and not just their weight on a scale.
The guidelines, says Bernadette Daelmans, coordinator in the department of maternal, newborn, child and adolescent health at the WHO, show that “we have created a movement.”
Food is just one part of the story
In the late 1980s, Sally Grantham-McGregor, an emerita professor of international child health at University College London, led a team of researchers in Kingston, Jamaica, who wanted to reverse or prevent the effects of poverty on children’s long-term life outcomes.
“Reach Up,” as the experiment was called, targeted underprivileged kids between 9 months and 2 years of age, some of whom suffered from stunting and malnutrition. (Children are defined as stunted if their height-for-age ratio is more than two standard deviations below the WHO Child Growth Standards median.) The researchers compared groups who received nutritional supplements, social stimulation, or a combination of the two. Only the children who received both nutrition supplements and social stimulation caught up to their non-stunted peers on developmental indicators. The effects were long-lasting: Twenty years later, the groups that received social stimulation had higher IQs and educational achievement, and better mental health and socio-emotional skills, than those who received only the supplements. There was no effect on the kids who received only nutrition supplements after they turned seven.
Grantham’s work showed that providing nutrition was not enough to help poor kids, and proved a major turning point in how international organizations like the WHO or Unicef thought about supporting families and breaking the cycle of poverty. Children need responsive and nurturing care too—like when a toddler makes a sound and her dad sings her a lullaby so she can go back to sleep, or when a baby babbles unintelligible words to his mother, and she responds as if they were having a conversation. In these scenarios, it might not seem like much is happening. But these exchanges are shaping a baby’s brain architecture. That is the foundational idea of the field of early childhood development: The best time to intervene in a child’s life in order to improve it is before they turn five.
“Reach Up,” which has now been adapted to five different countries, proved that it’s possible to improve poor children’s chances of having a healthy life by supporting families from even before the time the baby is born. Through monthly home visits from trained professionals, parents learned how to help their children develop cognitive, language, and psychosocial skills, which helps with self-control, the ability to work with others towards a goal, and emotional regulation.
Until very recently, there were almost no large investments in the lives of very young children, except in countries where significant portions were dying of preventable diseases or malnutrition. Governments largely considered their responsibilities towards children to start when kids entered school at age five or six; all the years before that were considered parents’ (and mostly mothers’) concerns. Starvation and disease were also more immediate and dramatic problems. In an imperfect world with scarce resources, feeding hungry children and immunizing them took precedence over improving the quality of the environment they grew up in.
But study after study began to show that “single interventions do not necessarily give the effect on growth that one might expect,” says Daelmans. In fact, says Debjeet Sen, a regional specialist in ECD and nutrition at PATH, a global health nonprofit, “less than one third of stunting can be prevented by scaling up nutrition-specific interventions.” The other two thirds “is this incredibly nebulous black box that includes everything from…the status of women in society to access to healthcare to exposure to pathogens and WASH [Water, Sanitation and Hygiene] practices.”
Nutrition interventions are also easier to implement. They hinge on figuring out what kind of supplement to give a group of children, then designing a study which gives them the supplement on a regular basis and measures the effect on height and weight over time (spoiler: Giving hungry kids food usually helps, at least at first). “The focus on stunting is not an accident,” wrote Rob Hughes, a senior fellow at the Clean Air Fund and expert on ECD, on Twitter. “[H]eight charts, rulers and centimeters are infinitely more explainable than multi-domain measures of child neurodevelopment to everyone from a mother (or father) to a minister.”
Programs aimed at improving the quality of relationships in the home, for example, or exposing kids to more learning and literacy, are more expensive and complicated. They’re also not an exact science, says Sen. “You can’t just say: ‘Give a child 21 playthings and not one less and not one more’ or, ‘You need to talk to a child for four minutes and 32 seconds every six hours.’ It’s meant to be a continuous give-and-take process where you’re picking up the signals from the child, you’re responding to the child’s interests, and promoting its development.”
That kind of intangible exchange, which comes from a caregiver’s patience, love, and support for a child, is a lot tougher to teach or measure—and as the saying goes, you treasure what you measure.
Today, in the halls of the WHO, World Bank, or Unicef, it’s accepted that “if what you care about is human capital and cognitive development outcomes, then the very serious thing to be doing is talking, singing, playing, telling stories,” says Rachel Machefsky, an expert on ECD. “And that’s as essential, if not more essential than [a] good diet.”
Behind that reality lie decades of efforts to reframe the challenge of helping poor kids, so that just surviving war, poverty, or disease would no longer be enough.
From survive to thrive
World War II left many children traumatized and orphaned. When the United Nations convened its third session in 1948, it asked experts to study the needs of children who had been separated from their parents because of the war. They concluded two things (pdf): that to grow up healthy and well, “the infant and young child should experience a warm, intimate, and continuous relationship with his mother (or mother substitute) in which both find satisfaction and enjoyment,” and that “if a community values its children, it must cherish their parents”
From the 1960s to the 80s, public programs targeting kids mostly centered around childcare—as a way to get more women into the workplace—and nutrition and health as a way to fix the stunting crisis in poor countries. But eventually, says Daelmans, the global community got to asking, “If we help children to survive, do they thrive?” International institutions like the World Health Organization got involved. In 1980, for example, the WHO published a report called “Prevention in Childhood of Health Problems in Adult Life” (pdf), which began by stating what today may seem obvious: “Human health and wellbeing are the ultimate goal of development.”
While these political efforts were underway, Grantham’s study and others showed there was more to supporting children than calories. These included the Abecedarian project in North Carolina, the High/Scope Perry Preschool Project in Michigan, the Nurse-Family Partnership trials in New York, Tennessee, and Colorado, and more recently, the Educare study in Chicago. They all showed that high-quality early childhood programs can change the lives of poor children, and sometimes their parents too.
The 1980s and 1990s saw a movement of governments and international organizations to implement large-scale integrated programs targeting children’s health and development, including programs like Educa a tu Hijo (“educate your child”) in Cuba, a home-based and community-based program for caregivers of children between birth and age six. In 1994, the US Congress authorized Early Head Start, an extension of the $10-billion Head Start program, which made early learning and care services available to poor children under age three and pregnant women.
In the 2000s, three important research series about early childhood were published in The Lancet, a renowned medical journal—one in 2007, another in 2011, and the latest in 2016. Together, they made the case for investing in children and families, building up to a focus on “nurturing care” in 2016.
When the first two series were published, there was very little reaction outside of the expert community, says Linda Richter, a distinguished professor in the Centre of Excellence in Human Development at the University of the Witwatersrand in South Africa. But the 2016 series “really seemed to be the thing that lit the fire.” That’s because in 2012, the global community launched the Sustainable Development Goals (SDGs). While its predecessor, the Millennium Development Goals, succeeded in driving down child mortality and expanding primary education, the values that the SDGs promoted aligned particularly well with the goals of improving young children’s development, and interest in one fueled investment in the other, says Richter.
Suddenly the world was watching, and measuring.
The nurturing care revolution
On May 23, 2018, at the 71st World Health Assembly in Geneva, the WHO, Unicef, and the World Bank launched the nurturing care framework, a way for governments to think about supporting children beyond siloed investments in child health or nutrition or security. The best way to care for children, it said, is to guarantee five “inter-related and indivisible components,” namely “good health, adequate nutrition, safety and security, responsive caregiving, and opportunities for learning.”
“For the first time, there is a global framework which says very explicitly that maternal and child health services have to expand their mandate,” says Sen. Now, “they have to include promoting child development, it’s not just about promoting maternal and child survival.”
The nurturing care framework and the new WHO guidelines are not the same thing, though they build on each other. The framework convinced many countries to broaden the scope of their nutrition and health programs. Vietnam is piloting an Integrated Early Childhood Development program to foster holistic parenting in some provinces, and in Kenya, the government is planning to roll out more comprehensive nurturing care services for children between birth and age five across the county. In South Africa, authorities added “love” as one of the five core themes of the “Road to Health” card, a booklet given to new parents to record information about their baby for health workers.
And the WHO and a group of international funders and researchers are working on measurements of early childhood development that go beyond stunting. This will help raise money for ECD interventions from donors anxious for measurable benchmarks, and allow scientists to figure out what works best to help children thrive.
The guidelines do something that the nurturing care framework does not, says Nigel Rollins, a researcher on maternal, newborn, child and adolescent health at the WHO. They “tell us the quality and the nature of the evidence behind a recommendation.” And they help governments choose which interventions are feasible, equitable, and affordable, so as to eventually decide, “is this something that [we] should do and that communities and families would want?”
Programs that draw from the nurturing care framework could benefit from the legitimacy that the WHO’s new guidelines will bring. That’s especially true in low- and middle-income countries, where there are few or no local experts and research. Grantham-McGregor says that, when she reaches out to a new country to set up a version of “Reach Up,” one of her biggest struggles is to get governments on board. Now, “when you go to another country, you can say, WHO is saying this, [the] World Bank is saying this, Unicef is saying this. It all helps.”
“If WHO says it, people are more likely to pay attention.”
It took roughly 70 years to get responsive care and children’s development on countries’ agendas alongside nutrition or child mortality.
In a context of soaring global inequality, investments in the early years are one possible way to break a cycle of poverty that condemns some children early on to poor health and bad life outcomes. It could lead to countries “leapfrogging inequality,” meaning “rapidly accelerate” progress, “perhaps skipping steps but certainly ending up in a new place altogether,” according to Rebecca Winthrop, director of the Center for Universal Education at Brookings.
Behind the jargon and the policy are families and children who need help. Covid-19 has dramatically increased those needs. Hundreds of millions of parents are newly-unemployed. Countries where private daycare centers and preschools are the main option for childcare are emerging from lockdown only to find that many of them have shut down. Most of the world’s children are still stuck at home, many without enough to eat because their family has lost their livelihood. The WHO recently warned that “children will die” because they are not being vaccinated against preventable diseases like polio and cholera. While this crisis could represent an opportunity to invest in young children and families, it’s more likely that scarce resources will mean children continue to take a back seat.
Nothing happens overnight, says Richter. “There’s an expression in Afrikaans called padkos, which is food for the journey. I would say, pack your padkos, it’s going to be a long journey.”
Read more from our series on Rewiring Childhood. This reporting is part of a series supported by a grant from the Bernard van Leer Foundation. The author’s views are not necessarily those of the Bernard van Leer Foundation.