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Newsletter: From Evidence to Action

Early is best… but it’s never too late to help stunted children. The debate on 'catch up growth' and development for young children

Interesting debate and thoughts on catch up growth by Lawrence Haddad of the International Food Policy Research Institute (IFPRI). 

Catching up with the debate on catch up growth and development for young children

Below are two posts from important researchers working on infant and young child growth.  They both agree that the first 1000 day period after conception is a key intervention opportunity because growth velocity is so high.  They also agree that we should not restrict interventions to this period—we should take whatever opportunity in the life cycle that presents itself to invest in better nutrition.
Where the 2 sets of authors part company is on the nature of the evidence that supports their arguments for investments post the first 1000 day period.  Both authors think such investment is essential (we should never give up on a child!), but the Young Lives authors’ bolster their argument with the fact that for the children in their cohort studies, their standardised height for age scores (HAZ) improve between ages 5 and 8. 
Jef Leroy argues that the movements of HAZ do not reflect improvements in linear growth but are simply due to bigger standard deviations of HAZ as we move up the age groups.  Leroy says a better marker of any catch up growth would be the absolute difference between measured height and the median age- and sex-specific height obtained from the growth standards (HAD).  In addition, Leroy says while height is important for human development, the main story is in the things height is a marker for such as cognitive development and attainment.
If I were the Young Lives research team I would see if I can replicate my HAZ results with HAD.  I would also look at potential catch up in other markers of development such as cognitive attainment scores. 
Either way the policy implications are not very different for the 1000 Day period, but they could be for the post 1000 Day period: interventions to stimulate catch up in growth may be different from those to stimulate catch up in, say, cognitive attainment.  So it is important to air contrasting views.
Thanks to both blog authors and let the debate continue! 
Early is best… but it’s never too late to help stunted children
Paul Dornan and Andreas Georgiadis, Young Lives
The scale of the problem is immense: WHO global estimates suggest 162 million children under five are stunted (that is, too short for their age). Stunting is an indicator of chronic under-nutrition resulting from inadequate food intake, poor health, and poor child care. It is hard to underestimate the consequences of under-nutrition for child survival, health, and development, as it contributes to the deaths of 3.1 million children per year. Improving children’s nutrition should be at the heart of development policy.
There is consensus that good early nutrition is the foundation of children’s survival, growth, and learning. The Sustainable Development Goals reiterate earlier commitments to reduce the number ofstunted children under-5 by 40% by 2025. How would it be possible to achieve and surpass this target? Considerable recent attention has been given to nutrition and care during the first 1000 days after conception. Although this period of time is critical, there is growing evidence that improvements in children’s nutrition beyond that early period could yield additional benefits in terms of child development and well-being. That’s encouraging, as we need to make use of every opportunity to improve children’s nutrition. The evidence for this is set out in a new policy brief from Young Lives.
The good news is the attention nutrition has received in recent years. The London Olympics of 2012 was used by the British and Brazilian Governments, along with the Children’s Investment Fund Foundation to initiate the Global Nutrition for Growth Compact, with the stated aim of putting nutrition at the centre of development policy, which has now been signed by 26 Governments. Rio 2016 marks the point at which governments have committed to check in on the progress and to gather more supporters. The same initiative also saw the launch of the Global Nutrition Report, an authoritative advocacy tool providing strong evidence that emphasises the importance of action to improve nutrition.
Powerful arguments have emerged suggesting that experiences during the first 1000 days after conception (up to 2 years old) are critical for children’s later development. Some go further, arguing that beyond the first 1000 days, stunting and its implications for development are irreversible. The prioritisation of a focus on nutrition during infancy has important merits: children are most vulnerable and more likely to die as a result of poor nutrition and diseases during this period. And for those who survive, there are other important reasons to increase the focus on the very early years – with James Heckman, for example, identifying this period as the most efficient point to intervene to secure long-term benefits.
But while prevention is better than cure, there are increasing reasons to think that alone it isn’t enough. The evidence produced from analysis of the Young Lives cohort data, summarised in the policy brief, suggests that – first, while child growth is more plastic in infancy and early childhood, there is still potential for recovery of growth deficits and there is a risk for growth faltering  after the first 1000 days.
Therefore, interventions implemented during the first 1000 days should be sustained in order to promote growth recovery and prevent further faltering. Among the factors found to be associated with changes in growth after the first 1000 days were parental schooling, household poverty, maternal height, and community health infrastructure and these are some of the factors to be prioritised by policy interventions aiming to promote child growth and nutrition.
Alongside Young Lives, other studies have also produced evidence of post infancy growth changes. Analysis of the Cebu cohort study in the Philippines identified change in stunting and growth between age 2 and age 8 years and a recent multi-country analysis published by UNICEF’s Office of Researchalso emphasised the potential for catch-up growth. Evidence from Young Lives indicates that post-infancy physical recovery is associated with school attainment, suggesting that the gains may extend to other domains of children’s lives. While prevention of under-nutrition during the early days should be prioritised, there is still potential for interventions in later periods to tackle early nutrition and growth deficits.
So what does this evidence mean for policy and what should change?
1.     Nothing should undermine the central importance of the first 1000 days for child nutrition. But, the focus on the first 1000 days should not inhibit efforts to improve child nutrition in later periods.
2.     While it’s a traditional complaint that researchers always call for more research, in this case not enough is known about interventions which might bring about post-infancy recovery. Improving the knowledge base by trialling or testing post-infancy nutrition interventions may help to open up new opportunities to remedy under-nutrition and some of its consequences.
3.     One stand-out conclusion is that there is more potential in the role of the school for improving children’s nutrition, and that doing so can support better school attainment. Young Lives evidence suggests that school feeding programmes may promote growth recovery, particularly for children who were severely under-nourished in infancy. There is also evidence that nutritional supplementation in school-aged children can yield benefits in terms of children’s learning and performance in school. In short – let us have more thinking about the role of schools as a platform for interventions to support better nutrition.
Our new policy brief summarises the latest findings from an ongoing programme of work. We hope this work will open up new opportunities for sustaining and supporting children’s healthy development, showing that opportunities exist for a longer time window than sometimes thought. For the central message we end where we began: early is best, but it’s never too late.
Counterpoints : Read more HERE