SE M I N A R S I N P E R I N A T O L O G Y 39 (2015) 373–386

Available online at www.sciencedirect.com

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Enhancing the child survival agenda to promote,

protect, and support early child development
Sarah K.G. Jensena,1, Raschida R. Bouhouchb,1, Judd L. Walsonc,d,e,f,
Bernadette Daelmansb, Rajiv Bahlb, Gary L. Darmstadt, MD, MSg, and
Tarun Duah,n
a
Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
b
Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
c
Department of Global Health, University of Washington, Seattle, WA
d
Department of Medicine (Infectious Disease), University of Washington, Seattle, WA
e
Department of Pediatrics, University of Washington, Seattle, WA
f
Department of Epidemiology, University of Washington, Seattle, WA
g
Department of Pediatrics, and March of Dimes Prematurity Research Center, Stanford University School of Medicine,
Stanford, CA
h
Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland

article info abstra ct

Keywords: High rates of child mortality and lost developmental potential in children under 5 years of age
Early child development remain important challenges and drivers of inequity in the developing world. Substantive
Child survival progress has been made toward Millennium Development Goal (MDG) 4 to improve child
Intervention survival, but as we move into the post-2015 sustainable development agenda, much more work
Risk factors is needed to ensure that all children can realize their full and holistic physical, cognitive,
Life-course perspective psychological, and socio-emotional development potential. This article presents child survival
Integration and development as a continuous and multifaceted process and suggests that a life-course
Coordination perspective of child development should be at the core of future policy making, programing,
Scaling up and research. We suggest that increased attention to child development, beyond child survival,
is key to operationalize the sustainable development goals (SDGs), address inequities, build on
the demographic dividend, and maximize gains in human potential. An important step toward
implementation will be to increase integration of existing interventions for child survival and
child development. Integrated interventions have numerous potential benefits, including
optimization of resource use, potential additive impacts across multiple domains of health
and development, and opportunity to realize a more holistic approach to client-centered care.
However, a notable challenge to integration is the continued division between the health sector
and other sectors that support child development. Despite these barriers, empirical evidence is
available to suggest that successful multi-sectoral coordination is feasible and leads to
improved short- and long-term outcomes in human, social, and economic development.
& 2015 Elsevier Inc. All rights reserved.

Raschida R. Bouhouch, Bernadette Daelmans, Rajiv Bahl, and Tarun Dua are staff members of the World Health Organization. The
authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy, or views
of the World Health Organization.
n
Corresponding author.
E-mail address: duat@who.int (T. Dua).
1
Joint first authors.

http://dx.doi.org/10.1053/j.semperi.2015.06.002
0146-0005/& 2015 Elsevier Inc. All rights reserved.
374 SE M I N A R S I N P E R I N A T O L O G Y
Introduction
Mortality and lost developmental potential in children under
the age of 5 years remain important challenges in global
health and in the promotion of human capital develop-
ment.1,2 While significant progress has been made toward
achievement of Millennium Development Goal (MDG) 4 for
child survival,2,3 less progress has been made to secure
healthy child development.4 An improvement in child sur-
vival is expected to lead to an increasing number of children
who are at risk of adverse developmental outcomes, partic-
ularly in emerging economies.5 Thus, surviving children have
widely disparate opportunities to thrive and realize their right
to reach their full human potential and contribute to sustain-
able development.6
The holistic nature of child development is evident in the
broad range of sectoral inputs required, across health, edu-
cation, nutrition, and child protection. Addressing factors
across each of these sectors is essential for successful fulfill-
ment of children’s developmental potential.4,7 As programs
move toward the promotion of interventions best aligned to
meet the goals and targets of the Sustainable Development
Goals (SDGs) in the post-2015 agenda, a greater recognition of
the importance of child development is needed to realize
immediate and long-term impacts on individual’s and pop-
ulations’ health, and on economic and societal development.
The aim of this article is to present a life-course model of
multi-sectoral interventions for both child survival and child
development. Given the dynamic and interactive nature of
the many risk factors shaping early childhood development,
we argue that a concept of child development as a multi-
faceted continuous process has to be the focus of future
policy making, programing, and research. An important step
Fig. 1 – Model illustrating the overlap of major risk factors known to threaten child survival and child development.
39 (2015) 373–386
toward this end is to increase the integration of interventions
that promote both child survival and child development. It is
only by recognizing the importance of early child develop-
ment as a key to success that the SDGs may expand their
ultimate impact, address inequities, build on the demo-
graphic dividend created by improved survival, and maximize
gains in human potential.
The conceptual risk model: child survival and
development as a continuum
Early child development is affected by prenatal factors and is
continuously modified by events and exposures throughout
the life-course.8,9 Critical aspects of biological and cognitive
development take place early in life, as emphasized in the
first 1000 days initiative.10 Inability to reach developmental
milestones early in life is associated with profound long-term
adverse developmental implications.8 The risk factors known
to adversely affect child survival and child development are
often discussed separately, despite the clear linkages in their
pathways and outcomes (Fig. 1).
A dynamic interplay of risk factors affecting child survival
and development
The continued impact of early exposure to risk factors on
later developmental outcomes becomes particularly evident
when risks are considered along the full life-course (Table 1).
Risk factors present during fetal development have profound
long-term implications for a range of developmental out-
comes, including cognitive functions and performance.9,11,12
Maternal physical and mental health and nutrition, as well as
environmental factors, are known to affect the developing
Table 1 – Risk factors known to affect child survival and child development.

Pregnancy (maternal) Childbirth Child

Type of Pre- Antenatal Intra-partum Neonatal (0–28 days) Childhood (1–59 months)
risk pregnancy

Maternal Maternal obstetric history and previous miscarriages

health
Multiparity Low birth weight
Maternal sexually transmitted Preterm birth and birth Congenital morbidity and low birth
diseases including HIV and complications weight
syphilis
Maternal pregnancy-related Preterm birth and birth Congenital morbidity and low birth
disorders including complications weight

SE M I N A R S I N
hypertensive disorders
(eclampsia), jaundice, and
hepatitis
Maternal infection during Preterm birth and low Congenital morbidity and neurologic Mental
pregnancy including birth weight sequelae retardation

P
influenza

Maternal chronic disease
including gestational
diabetes
Maternal mental health and
stress
Maternal tobacco use
E R I N A T O L O G Y
Preterm birth Congenital morbidity, low or excessive Mental retardation
birth weight, respiratory distress
syndrome, and hypoglycemia
Preterm birth Low birth weight
Preterm birth Congenital morbidity, low birth Mental retardation

Maternal alcohol consumption
39 (2015) 373–386
weight, and neurologic sequelae
Preterm birth and low Congenital morbidity, including fetal Mental retardation
birth weight alcohol syndrome, and neurologic
sequelae

Nutrition Maternal malnourishment including related iron Preterm birth Low birth weight, malnourishment, and neurologic sequelae
deficiency anemia
Malnutrition
Stunted growth

Child health Birth complications Neurologic sequelae Mental

including asphyxia retardation
Low birth weight Neurologic sequelae
Hypothermia Congenital morbidity and neurologic
sequelae
Neonatal sepsis Congenital morbidity and neurologic
sequelae
Neonatal tetanus Congenital morbidity and neurologic
sequelae
Congenital abnormalities
Infectious diseases including pneumonia, diarrhea, malaria, measles, and HIV/AIDS
Chronic illness and disability

375
Injury
376 SE M I N A R S I N P E R I N A T O L O G Y 39 (2015) 373–386

fetus. Maternal malnourishment and micronutrient deficien-

in bold. The table also includes associated risk factors that commonly co-occur with the initial risk factors (for example, multiparity is a risk in itself but is also associated with increased risk of birth
Risk factors are divided into five domains (column 1) and organized across the developmental time span from pre-pregnancy to early childhood. Main risk factors within each domain are highlighted
cies are associated with intrauterine growth restriction and
impaired neurological and cognitive development.13–16 Mater-

Infant/child exposed to toxins

Lack of cognitive stimulation

nal iodine deficiency can, for instance, cause impaired devel-

Parental psychopathology
Lack of social stimulation
Childhood (1–59 months)

opment of the central nervous system and congenital

Poor parental education

hypothyroidism, which in turn is associated with mental

Exposure to violence
retardation and cognitive impairment.17–19 Iron deficiency
anemia also has adverse consequences for the developing
fetus, including impaired mental, motor, and socio-emotional
development.19–24 Maternal infection during pregnancy is
associated with impaired physical growth and neurological
sequelae,25,26 as are maternal behaviors such as smoking,

complications, preterm birth, and low birth weight). The associated risk factors illustrate how an initial risk factor is likely to continue to affect development.
alcohol consumption, drug abuse, and environmental expo-
sures to heavy metals and environmental toxins.27,28
During labor and in the neonatal period, prematurity and
perinatal asphyxia (Table 1) constitute important risks for
child mortality and in surviving children may result in
neurological damage with long-lasting consequences for
cognitive and motor development.29–31 At least four million
Neonatal (0–28 days)

term or near-term neonates each year have life-threatening

conditions that result in life-long impairments, while the 15
million preterm babies born each year account for more
disability-adjusted life years (DALYs) than HIV/AIDS.32 In
addition, infectious diseases pose a major threat to child
Child

survival during postnatal development33 and have been

shown to directly impact on children’s physical growth and
cognition.34–36 Child malnutrition, as a consequence of poor
nutritional intake and/or repeated infections, is directly or
indirectly associated with 45% of under-five mortality and is
an important risk factor for poor growth and early cognitive
development in the under-five population.7,37,38
Intra-partum
Childbirth

Role of the caregiving environment

Child survival is dependent on the ability of the caregiver to

meet the child’s physical and emotional needs and to protect
the child from the adverse consequences of life-threatening
exposures. The caregiving environment also has direct impli-
cations for child development and learning (Table 1).39 Care-
giver–child interactions facilitate the development of early
self-regulatory mechanisms by providing a safe environment
in which the child can begin to engage with the social world
and further by stimulating the child’s acquisition of strategies
to regulate emotional arousal.40 In addition, stimulating
Antenatal

caregiver–child interactions creates an environment in which

Poor hygiene and sanitation
Mother exposed to toxins

the child learns to cope with stress, which has profound

implications for normal cognitive and emotional develop-
Pregnancy (maternal)

ment.9,41,42
A poor caregiving environment, which may be due to
absence or failure of caregiver responsiveness toward the
pregnancy

emotional and social needs of a child, constitutes a risk factor

for poor development. Estimates from UNICEF global data
Pre-

(2014) based on Demographic and Health Surveys (DHS) as

Table 1 (continued) )

well as Multiple Indicator Cluster Surveys (MICS) indicate that

approximately 6 in 10 children worldwide between 2 and 14
Psycho-social

years of age are subjected to physical punishment by their

Environment

education

caregivers on a regular basis, and that as many as 3 in 10

Type of

adults believe that physical punishment is necessary in order

and

to raise and educate a child properly.43 Violence is wide-

risk

spread across age groups, and the percentage of children

 S E M I N A R S I N P E R I N A T O L O G Y
between 2 and 4 years of age who experience any violent
discipline during the span of a month varies from about 40%
up to above 90% in countries around the globe. Furthermore,
up to 60% of under-five children are left alone or in the care of
another child under 10 years of age, depending on the
country.44
Maternal depression has also been associated with a range
of factors that are likely to contribute to increased risk of
child mortality, including preterm birth, low birth weight,
acute and chronic malnutrition, risk of infectious disease,
and reduced compliance with recommended immunization
programs.45–48 The mean prevalence rate of postnatal mater-
nal depression in low and middle income countries is about
20%, and maternal depression is especially common among
women who experience other risks related to poverty, hous-
ing inadequacy, violence, and low levels of support.45,49,50
Much of the adverse effect of maternal depression on child
development is believed to be mediated via compromised
caregiving and poor mother–child interactions.45,51 Data from
high-income countries suggest that depressed mothers are
less sensitive, less responsive, and more intrusive in their
interactions with their child.52
Biological and genetic predisposition to risk factors
Mediating neuro-endocrine pathways
Factors that threaten child survival are likely to co-occur with
other risk factors for poor developmental outcomes, includ-
ing poverty, inadequate housing, overcrowding, violence, and
poor parental mental health. Stressful environments cause
increased activation of the hypothalamic–pituitary–adrenal
(HPA) axis and elevated levels of the stress hormone corti-
sol.53 The brain can handle moderate levels of stress hor-
mones, which serve to mobilize and monitor an appropriate
stress response in situations where this is required (such as
perceiving and responding to a threat in the environment).
Excessive levels of stress hormones, however, can have
pathogenic effects on the brain, leading to cell death and
later, dysregulation of the HPA axis. Both brain atrophy and
HPA axis dysregulation can have long-lasting impacts on
learning, behavior, and health.54 High levels of stress are
related to impaired fetal and postnatal brain develop-
ment.9,55,56 These effects may be particularly detrimental
early in life when important neurological development takes
place.9,12
Embedding within the epigenome
Epigenetic mechanisms are processes through which the
environment interacts with genetic predispositions and
changes the function of the DNA without changing the DNA
sequence. Epigenetic mechanisms constitute an important
pathway through which environmental exposures directly
affect human biology and have gained increased attention
because of their apparent long-term impact on health and
development.57,58 Moreover, epigenetic changes can also be
passed from one generation to the next.59
During fetal development, factors that are known to impact
on health of the mother—such as her diet,58,60 alcohol
consumption, smoking and exposure to environmental tox-
ins and pollutants,61,62 mood,55,56 and infection—have been
39 (2015) 373–386 377
found to also impact the epigenome of the fetus, leading to
adverse effects on health and development. Epigenetic mod-
ifications have been observed in individuals exposed to social
stressors such as abuse,63 low socio-economic status,64 and
institutionalization.65 Animal studies have shown that a
manipulation of the quality of the early caregiving environ-
ment can affect the epigenome and that low levels of
maternal caring behavior are related to alterations of gluco-
corticoid receptor gene methylation and poor regulation of
the HPA axis and its mediation of stress responses.66 Epige-
netic mechanisms may also play a role in poor developmen-
tal outcomes that result from exposures to infection.58
Evidence for a dynamic life-course model of
synergistic interventions for child survival and
development
Many health interventions that aim to prevent child morbid-
ity and mortality also impact children’s development. The
main domains of child survival and child development
interventions are outlined in Table 2.
Maternal antenatal and neonatal health interventions
Many maternal antenatal (e.g., family planning, immuniza-
tion, nutrition, and cessation of smoking, and substance
abuse) and newborn (e.g., essential newborn care, early
initiation and exclusive breastfeeding, case management of
infections, and birth-related complications) health interven-
tions have been found to be associated with improved child
growth and development.67,68 For example, interventions to
care for preterm babies to prevent excess mortality include
thermal care, tactile stimulation, breast milk feeding, and
kangaroo care, and these have shown direct impacts on child
growth and development. Kangaroo mother care results in
improved mother–infant interactions and increased uptake
and continuation of breastfeeding,69,70 as well as improve-
ments in early childhood cognitive development, particularly
in preterm infants.71
A recent review of 13 intervention trials conducted in low-
and middle-income countries, with the aim to reduce mater-
nal postnatal mental disorders including depression, found
both reduced maternal depression and improved child devel-
opmental outcomes.72 Six of the 13 studies reviewed also
aimed specifically to improve infant heath and development
via elevated maternal mood, knowledge, and caregiving
skills, and most showed a positive impact on child morbidity
and development.72 Importantly, the review demonstrated
that maternal depression interventions can be successfully
integrated into existing antenatal or postpartum health care
interventions.72
Nutrition interventions
Interventions to support or promote optimal breast-feeding
practices have been shown to improve child survival73 and
child nutritional status,74 reduce childhood infections, and
protect against common childhood diseases.75–78 Remarkably,
increased breastfeeding is also associated with improved
378 SE M I N A R S I N P E R I N A T O L O G Y 39 (2015) 373–386

Table 2 – Interventions impacting child survival and child development.

Maternal Promotion of adequate maternal nutrition

health Maternal immunization: Tetanus toxoid vaccine (pregnant women)
Family planning: Birth spacing and modern family planning methods such as pill, condom, injectable contraceptives, etc
Cessation of smoking and substance abuse
Detection of genetic conditions
Prevention of exposure to environmental toxins
Prevention of intimate partner violence
Detection and care for maternal mental health problems: Support for mental health
Antenatal care by a skilled provider: Antenatal visits
Management of pre-eclampsia (magnesium sulfate)
Management of pregnancy complications
Childbirth care by a skilled provider
Postnatal care by a skilled provider
Promoting health literacy and support for healthy life styles
Detection and prevention of maternal obesity and support for healthy life styles
Detection and management of diabetes in pregnancy
Detection and management of fetal growth restriction
Prevention and treatment of maternal infections: Prevention of mother to child HIV transmission, HIV—ART (first-line for
treatment) for pregnant women, and syphilis detection and treatment in pregnant women
Prevention and treatment of malaria in pregnancy: Use of insecticide-treated materials, pregnant mother sleeping under an
insecticide-treated bed net, intermittent preventive treatment for pregnant women, and treatment of malaria in pregnant women
Preparedness
Maternal empowerment
Addressing adolescent health needs and agency for decision making to promote health and development

Child health Skilled attendance at delivery

Immunization
Prevention and integrated management of newborn conditions: Kangaroo care, newborn care, clean birth practices, antenatal
corticosteroids for preterm labor, antibiotics for preterm premature rupture of membranes, induction of labor, neonatal infections or
newborn sepsis, and full supportive care
Prevention and integrated management of childhood illnesses
Management and therapies for diarrhea: Zinc supplementation, oral rehydration therapy, and antibiotics for treatment of dysentery
Preventive postnatal care
Malaria treatment
HIV prevention and treatment: (Prevention see Maternal Infection above), Co-trimoxazole for children and pediatric ART
(antiretroviral therapy)
Deworming treatment
Measles treatment: Vitamin A for measles treatment
Support for learning: Counseling on Care for child development, parent support training on responsive parenting skills,
stimulation, and early learning informal and formal approaches

Nutrition Maternal micronutrient supplementation and fortification of staple foods: Iron and folic acid supplementation
Access to adequate, nutritious, and safe diet: Counseling on adequate diet for pregnant mothers
Prevention and treatment of acute malnutrition: Counseling on infant and young child feeding and management of feeding
difficulties and inadequate growth
Micronutrient supplementation or fortification of weaning foods: In-home fortification using micronutrient powders or sprinkles

Environment Prevention of child maltreatment, abuse, and neglect: Child protection services
Prevention of violence in the home and community
Access to safe water: WASH
Adequate sanitation: WASH
Adequate hygiene and hand washing: WASH
Access to electricity
Safe places for play
Prevention of exposure to toxins such as lead, mercury, and pesticides
Prevention of indoor and outdoor air pollution

Education Maternal education

Early stimulation: Parenting training and introduction of psycho-social stimulation (play and responsive parenting)
Pre-primary education: Daycare
Preschool education
Continuity to primary school

Social Social assistance and cash transfer schemes

protection Birth registration
Parental leave and child care
Child protection services

Interventions have been divided into six main domains (first column). Categories of interventions are marked in bold and illustrative examples
of interventions are marked with italics.
 S E M I N A R S I N P E R I N A T O L O G Y
cognitive and motor development.79–81 Appropriate comple-
mentary feeding in children 6 months to 2 years of age, such
as responsive feeding, is also associated with improved
growth and development.19
Some evidence suggests that nutritional supplements pos-
itively impact a range of developmental outcomes including
growth, cognition, and motor development.82–85 Importantly,
it appears that interventions that combine some form of
nutritional supplementation with child stimulation or paren-
tal education may be most effective. Inconsistencies in
findings across studies are partly due to methodological
variations such as varying timing of the intervention, meas-
urement of outcomes, and the risk status of the child.83,86,87
With regard to children’s cognitive development, Prado and
Dewey82 reviewed findings from randomized controlled trials
of nutritional supplementation (including food supplements
with micronutrients or balanced protein and energy) delivered
to mothers during pregnancy and children during infancy, and
they examined how these interventions impacted children’s
cognitive development. They concluded that supplementation
with iron and/or micronutrients, fatty acids, and fortified foods
during pregnancy and infancy are promising interventions to
promote child development. Nores and Barnett87 reviewed the
impact of quasi-experimental and randomized nutrition inter-
ventions on children’s cognitive outcomes. They found a
modest effect of nutrition interventions alone across studies
and a strong effect of nutrition interventions combined with
child education or stimulation.87
Some studies, including randomized trials, have also
shown positive effects of nutritional supplementation on
children’s motor development,85,88 although less evidence is
available. Finally, nutrition-sensitive interventions that
address societal conditions, such as poverty alleviation and
women empowerment, along with household considerations,
such as mealtime organization and family feeding interac-
tions, are critical not only to improve nutritional status but
also to strengthen children’s development.89
Childhood health interventions
Immunization and timely case management of childhood
illnesses (such as diarrhea and pneumonia) are important
intervention strategies to prevent and treat infections,
respectively, and may have positive effects on developmental
outcomes, including improved cognition and school achieve-
ment through prevention of the adverse effects of infection
on child development.90 Helminth infections or other para-
sitic worms affect a large number of children in the develop-
ing world. While parasitic worms may only pose a threat of
survival in children with other comorbid conditions, worm
infections alone may be associated with poor developmental
outcomes including poorer cognition.91 A recent review found
that deworming interventions have a positive impact on child
growth.92,93 However, pooled analyses did not demonstrate
clear evidence of an effect of deworming on cognition,
although some individual studies did.94–96 The inability of
some studies to detect developmental gains might relate to
methodological limitations; more well-designed trials are
therefore needed to assess the impact of deworming on
children’s cognitive development.93 Malaria interventions in
39 (2015) 373–386 379
Africa over the last 10 years have proved safe and effective in
decreasing child mortality and morbidity and may also have a
positive impact on child development, although more direct
evidence is needed.97,98
Environmental and social interventions
Environmental interventions include water, sanitation, and
hygiene (WASH) interventions; provision of safe places to
play; and prevention of toxic environmental exposures.
Evaluations of WASH interventions primarily focus on their
ability to reduce child morbidity99,100 and associated improve-
ments in developmental outcomes.19,37 Recent reviews have
shown a direct effect of WASH interventions on child
growth.101,102 There is some evidence that WASH interven-
tions may improve children’s cognitive development,103
though more research is needed to examine the impact of
WASH interventions on children’s cognitive, socio-emotional,
and motor development. Several large randomized trials of
WASH interventions are currently underway and will provide
important data to inform the potential of these interventions
to improve early childhood development.37
Implementation research has also demonstrated that
sustained improvement in child survival is not possible
without health systems strengthening and improvement in
social determinants.2 Social assistance transfer programs
can help parents provide for their children’s needs and
invest in their children’s nutrition, health, and education.
Social protection programs can also help to protect families
from income shocks and children from a range of conse-
quences including toxic stress.104 One of the most well-
known conditional cash transfer programs that has served
as a model for numerous later programs is Oportunidades
(previously known as PROGRESA) from Mexico. Oportuni-
dades provides cash grants to poor rural families on the
condition that children regularly attend school and visits
health clinics. Evaluations of the program have shown
significant positive impacts on child health outcomes
including improved height (if the program started when
the child was young), improved cognition, and increased
school enrollment.105
Stimulation and parenting interventions
Interventions that promote parenting practices and improve
mother–child interactions offer important opportunities to
reduce or mitigate the effects of biological and physical risks
and thereby enhance the child’s chances of survival as well
as healthy development. Importantly, the effectiveness of
interventions to increase parenting skills justifies the inte-
gration of early infant stimulation programs into existing
health services.71,106,107
Stimulation interventions use cognitive and psycho-social
stimulation to support children’s development and can be
delivered by community workers and/or via parent counsel-
ing and training. Parent interventions also include parenting
training, counseling, and education to improve parent’s
responsiveness and sensitivity to the child. Stimulation
and parenting interventions are commonly implemented
with the objective of supporting child development,71,107,108
380 SE M I N A R S I N P E R I N A T O L O G Y
but they are also likely to impact children’s health and
survival.
Evidence suggests that parenting interventions, including
education, can promote positive child health-related behav-
iors of parents, both directly and indirectly. Parent education
interventions have been successful in guiding parents toward
providing safer and healthier home environments and other
health-related behaviors.106,108 Maternal education has been
linked to both improved child survival and child develop-
ment.109 Evidence demonstrates the importance of girls’
education for early child development. When girls attain a
higher level of education, it can have a powerful influence on
their future children.104
Educational interventions have led to improvements in
infant sleeping position, which is known to increase child
survival.106,110 Nutrition education of parents is also related
to improved survival and health via improved feeding
behaviors.108 Parental hygiene education has been shown
to effectively reduce child infection and mortality via behav-
ioral change among parents.111,112 Parenting interventions
have also been shown to promote breast-feeding behav-
iors.113 Breastfeeding is, as outlined above, associated with
increased survival and decreased morbidity,73,76 and
randomized controlled trials of breast-feeding interventions
have been shown to decrease child morbidity and improve
cognition.77–79,114
Other positive outcomes of parenting interventions include
improved parenting skills and well-being, both of which may
indirectly affect child survival by increasing the parents’
ability to understand their child’s needs, detect illness, and
seek help. Parenting interventions have also been found to
improve the quality of mother–infant interactions,115
improve parents’ knowledge of child development,116,117
and lower the level of maternal postnatal depression.72 One
of the most promising ways to promote development for the
youngest children, including in resource-poor communities,
is the WHO/UNICEF evidence-based intervention on Care for
Child Development, which promotes child learning and
development through play and communication with a caring
adult.118–120 The interactive activities provide a context for
strengthening the responsiveness of caregivers, a skill
needed, for example, for effective feeding practices, enriching
a child’s learning, recognizing signs of illness, as well as
protecting against maltreatment. When integrated with
nutrition interventions, Care for Child Development has been
shown to enhance the effects on growth.121
Preschool interventions
Preschool interventions are mainly assessed based on their
success in improving children’s developmental outcomes.4
However, attendance at preschool also offers an opportunity
to monitor children’s health and to teach children healthy
and safe behaviors. Daycare and preschools provide settings
in which the physical and mental health of the child can be
continuously monitored by trained facility workers and
where health interventions, such as deworming, can be
implemented effectively at a low cost (Fig. 2).
39 (2015) 373–386
Optimizing benefits via integrated child survival
and development
As discussed above, interventions to promote child survival
and child development work toward the same ultimate goal:
a safe and healthy start to life, ensuring that all children can
live healthy and productive lives. Therefore, improved inte-
gration and coordination of child survival and child develop-
ment programs is needed in order to promote a holistic and
multifaceted life span approach to child care and develop-
ment. Many of the factors that drive poor development early
in life are multifactorial and cannot appropriately be
addressed by single-focused interventions, targeting only
one facet of risks. Despite limited evidence of synergistic
effects of integrated interventions, which is partly due to the
way previous studies have been designed, a strong body of
evidence suggests that parenting interventions can be inte-
grated into other more health-focused interventions to max-
imize positive effects of the intervention on child
development. Three recent reviews examining effects of
combined child development and nutrition interventions
have found positive effects of combined interventions includ-
ing additive effects (i.e., positive effects of an integrated
intervention that is greater than either alone because both
the interventions have independent positive effects that add
up).87,107,122
Benefits of integration of child survival and development
Policy level
Coordination of interventions across multiple sectors, includ-
ing health, nutrition, education, and child protection,
presents a potentially cost-effective way to promote both
child survival and development by addressing an overlap of
risk and protective factors at the same time. The challenge is
to ensure alignment of investments, coordinated planning,
and harmonized implementation between different relevant
departments in ministries of health and between health and
other sectors.
Program level
At the program level, integration of existing interventions
optimizes resources by using an already established contact
with the population.10 The World Bank recently published a
report concluding that investment on human capital early in
life gives higher returns than investments targeting later
intervention.104 Recent cost-effectiveness analyses of inte-
grated interventions also support the economic rationale for
integration. Gowani et al.123 examined the cost-effectiveness
of the delivery of an integrated stimulation and nutrition trial
in Pakistan and found that early childhood interventions that
included responsive stimulation were more cost-effective in
promoting children’s early development compared with the
nutrition intervention alone. In a recent evaluation of an
integrated stimulation and nutrition trial in Nicaragua,
assessing cost-benefits of interventions in a long-term per-
spective including both economic returns and human capital
development, Lopez-Boo et al. estimated that the program
will be fully paid back in gains on adult earnings after 20
 S E M I N A R S I N P E R I N A T O L O G Y
Fig. 2 – Social and biological pathways though which risks factors that threaten child survival may also affect children's
development.
years of labor market participation from children who
received the intervention.124 Clearly, this is an area that can
benefit from further research, as the findings are critical for
priority setting and decision making.10 Integrated manage-
ment of childhood illness (IMCI) is an example of a key
strategy that integrates preventive and curative interventions
and focuses on strengthening health facility as well as
community delivery platforms.118–120 IMCI not only focuses
on the management of childhood illness, its guidelines and
tools also contribute to prevention of illness and optimizing
caregiving practices including for feeding and development. A
multi-country evaluation of IMCI has shown that if the
strategy is fully implemented, it improves quality of care,
increases utilization of health services, reduces child mortal-
ity, and is cost-effective.125
Community level
At the community level, opportunities exist to develop and
deliver interventions to improve maternal–child care behav-
iors that will ultimately impact both child survival and
mitigate lost developmental potential. The WHO and the
UNICEF have developed materials on Caring for newborns and
children in the community, based on evidence of effective
community interventions.118–120 Globally, an increasing num-
ber of countries are engaging community health workers as
an extension of the formal health workforce, in particular, in
low-income countries. Continued and integrated care, includ-
ing through community-based platforms and delivery chan-
nels, is important for achievement of greater equity, as lost
developmental potential among children in low resource
settings is highly associated with poor educational attain-
ment and achievement. If not targeted, these children go on
39 (2015) 373–386 381
to have low income-generating potentials, enforcing a vicious
circle of an intergenerational transmission of poverty.
Challenges in integration of child survival and
development and ways forward
An important challenge in promoting integration of child
development interventions into other programs is that
although child survival is the responsibility of the health
sector, multiple sectors are responsible for child develop-
ment. Policies regarding child development can fall under
ministries and departments for health, as well as nutrition,
education, social welfare, and many others. This leads to a
lack of common financial/budgetary space that covers both
child survival and child development. The challenges at the
policy level therefore require skillful coordination across
sectors. Governance and leadership are needed to guide the
sectorial coordination and integration of competences and
finances,2,3 and partnerships are needed to effectively pro-
mote early child development given its broad range of
economic and social determinants. A greater understanding
of how these partnerships can lead to increased coordination
of policy and programs is urgently needed. Governance is also
needed to ensure that programs are embedded into an
integrated measurement framework for child survival and
child development, to ensure evidence-based quantification
of the progress achieved by policies and programs, and to
translate knowledge from existing programs into continuous
program improvement and into future initiatives.
A challenge at the program level is that more evidence is
required from implementation to support integration of
382 SE M I N A R S I N P E R I N A T O L O G Y 39 (2015) 373–386

interventions. There is a clear need for additional rigorous
studies to examine the additive effect of interventions that
are not purely child survival focused but aim to also enhance
child development. Of the studies that have examined effects
of integrated interventions, some report rather subtle effects
of child development interventions on child health,121,122
perhaps because the effects are likely to work via a chain of
events involving parenting, adaptation of the neuro-
endocrine system, as well as epigenetic modifications as
potential mediators, as discussed above. These indirect path-
ways are rarely taken into account when evaluating inter-
ventions. Another important potential cause of attenuated
effects observed in evaluations is that impacts of early
childhood interventions may not be visible until the child
reaches certain developmental milestones.8,9 Finally, a num-
ber of factors have been found to impact the effectiveness of
interventions on child development, including timing and
duration of the intervention as well as specific aspects of the
intervention.4,87
Another challenge is related to monitoring of child develop-
ment, as it often focuses on rather young children using as
little as one or two health or nutrition indicators, which are
undoubtedly of importance, but a more holistic assessment is
crucial in order to address the multifactorial nature of child
development. For monitoring and evaluation of policies and
programs, a set of population-based indicators is essential.
Setting global standards for assessment is key to improve the
effectiveness of interventions and programs. A measurement
framework has to address not only older children but should
include every child from birth up to 8 years of life to build
upon and integrate into existing population-based assess-
ments. At the program level, we need evidence that takes a
life-course perspective into account for planning and evalua-
tion of future interventions.
Lessons from successful integration
Experiences from previous integrated child development
programs provide an essential starting point for the design
and implementation of future integrated programes. A num-
ber of reviews have examined effectiveness factors for suc-
cessful integrated interventions (Box 1).4,87,107,121 These
factors should be considered when designing and imple-
menting integrated interventions, although we still urgently
need studies that compare the relative effectiveness of differ-
ent modes of delivery. Some of these factors are closely
related to expenditures, including the intensity and duration
of the program, and we need to learn more about how these
factors relate to the sustainability of intervention effects and
to the economic returns of the program. Other factors are not
necessarily related to the cost of the program but include
timing of the intervention and factors related to the design,
such as active parent involvement and use of feedback to
inform program improvement.
Lessons from scaling up early child development programs
A number of countries, predominately high-income coun-
tries, have started to implement child development interven-
tions at a national level at scale, building on strong political
commitment and policy formulation aimed to overcome
social determinants of health and child development, such
as inequity, poverty, and low education. The lessons learned
from scaling up national programs in countries such as
Australia, Canada, the United States of America, or the United
Kingdom, as well as in developing countries such as Chile,
South Africa, Bangladesh, and India, among others, should be
assessed and evaluated regarding costs as well as long-term
impacts. This learning is essential in order to inform future
programs and policies throughout the world, to ensure
quality for both short-term and long-term outcomes, and to
reach the most vulnerable both in developing and more-
developed countries.126 A recent trial in Colombia provides a
starting point and potential implementation model for future
delivery of stimulation interventions at scale.127 The trial
used the infrastructure of a national welfare (cash transfer)
program to deliver an intervention that integrated stimula-
tion and nutritional supplementation at scale, and it provides
important insights into successful aspects of the intervention
as well as aspects that can be improved in future programs.
Box 2 provides a summary of key lessons learned from
previous programs taken to scale, stressing the importance
of coordination.

Box 1–Effectiveness factors in integrated interventions (based on previous reviews4,87,107,121,123).

Intensity: The frequency of contacts with professional health workers is associated with higher effectiveness.
Duration: Longer interventions are typically found to be more efficacious.
Timing: Start early in the life-course; the 1000 days from conception to 2 years of age is a special window of opportunity
for healthy growth and development.
Targeting: Programes targeting children who are at risk tend to be most effective.
Factors related to effectiveness of programs:
Adequate training of workers
Implementation of a well-structured curriculum
Comprehensive focus on health, nutrition, and education aspects
Joint parent and child focus
Active inclusion of caregiver and direct learning including opportunities for parents to experience play and to
communicate with their children and receive feedback.
 S E M I N A R S I N P E R I N A T O L O G Y 39 (2015) 373–386 383

Box 2–Key lessons from existing national programes at scale.126

A high level of government commitment and leadership is needed to coordinate political and technical agendas across
government departments. Importantly, these agendas need to be driven by a general political concern regarding the
welfare of children and their families.
A comprehensive approach should focus on coordination and strengthening of existing services.
Investigation of how interventions can be adapted to local contexts, especially in low- and middle-income countries,
needs to be examined across multiple levels of services (including community, primary, and referral services) to reach
each and every child.
Effective partnerships are needed to implement large integrated programs: this requires skillful coordination of services,
funds, and accountability frameworks that guide roles and responsibilities.
High-quality services require multiple delivery platforms and approaches requiring clear communication and
coordination. Many large-scale programs use a combination of home visits, community centers, and health
facility contacts. An effective approach has been a 2-generational approach that provides targeted help to
parents aimed to build capacity within the family. This requires coordination across services and health care
providers.
Sustainable programs need to provide social protection to secure economic stability within the family.

refere nces
Conclusions

Child development is a multifaceted and continuous process.
A life-course perspective of child development should there-
fore be at the core of policies, programs, and research aimed
to secure children’s rights to healthy growth and develop-
ment, thereby reducing inequities and enabling all people to
attain their full potential and contribute to sustainable social
and economic development.
Child survival and child development have typically been
the concern of different sectors and streams of policy making
and programing. Consequently, an important challenge for
integration has been a lack of a common financial and policy
space covering both child survival and child development.
We identified two immediate priorities to support the imple-
mentation of a life-course approach in child development.
First, increased coordination of the delivery, monitoring, and
assessment of existing child health and child development
programs across health care and other sectors is needed at
both national and global levels. Second, we highlight the
essential need to overcome existing knowledge gaps. At the
program level in particular, there is a need for more evidence
of the additive effects of integrated interventions, on effec-
tiveness, costs, and impact. Nevertheless, available knowl-
edge allows for a compelling case that the time is right for
breaking down boundaries and expanding the scope of
actions across sectors, including health, nutrition, education,
and social protection. The global community concerned with
the health of women, children, and adolescents is respond-
ing to the imperative to act by formulating a new Global
Strategy for Women’s, Children’s, and Adolescents’ Health
that is stronger than ever before is built on a life-course
perspective and recognizes the need for multi-sectoral
actions. The strategy firmly anchors interventions for child
survival and development together as part of the seamless
continuum of care that is essential for every individual, every
family, and every community to be able to survive and thrive
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