Patrice Engle
Patrice Engle
Patrice Engle
Child Development 2
Strategies for reducing inequalities and improving
developmental outcomes for young children in low-income
and middle-income countries
Patrice L Engle, Lia C H Fernald, Harold Alderman, Jere Behrman, Chloe O’Gara, Aisha Yousafzai, Meena Cabral de Mello, Melissa Hidrobo,
Nurper Ulkuer, Ilgi Ertem, Selim Iltus, and the Global Child Development Steering Group
This report is the second in a Series on early child development in low-income and middle-income countries and Lancet 2011; 378: 1339–53
assesses the effectiveness of early child development interventions, such as parenting support and preschool Published Online
enrolment. The evidence reviewed suggests that early child development can be improved through these interventions, September 23, 2011
DOI:10.1016/S0140-
with effects greater for programmes of higher quality and for the most vulnerable children. Other promising
6736(11)60889-1
interventions for the promotion of early child development include children’s educational media, interventions
See Editorial page 1276
with children at high risk, and combining the promotion of early child development with conditional cash transfer
See Comment page 1277
programmes. Effective investments in early child development have the potential to reduce inequalities perpetuated
This is the second in a Series
by poverty, poor nutrition, and restricted learning opportunities. A simulation model of the potential long-term of two reports about child
economic effects of increasing preschool enrolment to 25% or 50% in every low-income and middle-income development
country showed a benefit-to-cost ratio ranging from 6·4 to 17·6, depending on preschool enrolment rate and Psychology, California
discount rate. Polytechnic State University,
San Luis Obispo, CA, USA
(Prof P L Engle PhD); School
Introduction Children in the highest income quintile in a particular
of Public Health, University
This report, the second in a Series, assesses the effectiveness country are more than twice as likely to attend preschool of California at Berkeley,
of early child development intervention programmes in (figure 1) as those in the lowest quintile in the same country, Berkeley, CA, USA
low-income and middle-income countries, calculates the and are also more likely to have higher quality stimulation (L C H Fernald PhD);
Development Research Group,
cost of not investing in early child development, and builds in the home (figure 2), as measured by Family Care The World Bank, Washington,
on the 2007 Series in The Lancet on child development.1–3 Indicators (methods for both figures described in panel 1). DC, USA (H Alderman PhD);
The first report4 of the present Series identified social– Similarly, children aged 5 years in the highest-income Department of Economics
cultural, psychosocial, and biological risk and protective and Department of Sociology,
University of Pennsylvania,
factors that affect child development. The theoretical Philadelphia, PA, USA
framework used in both reports, presented in the first Key messages (Prof J Behrman PhD);
figure of the first report, illustrates how children’s • Early childhood is the most effective and cost-efficient The William and Flora Hewlett
developmental trajectories are affected by biological Foundation, Menlo Park,
time to ensure that all children develop their full CA, USA (C O’Gara PhD);
systems and by positive and negative risk and protective potential. The returns on investment in early child Department of Paediatrics
factors. The intensity of these effects relates to the development are substantial. and Health, Division of
developmental periods in which the risk factors happen • Reducing inequalities requires integrated interventions Women and Child Health,
(timing), the dose or extent of the risks (exposure), and the Aga Khan University, Karachi,
early in life that target the many risks to which vulnerable Pakistan (A Yousafzai PhD);
child’s individual reactivity (temperament) to the risk and children are exposed. World Health Organization,
protective factors. Effective programmes, policies, and • Parenting interventions and centre-based programmes Geneva, Switzerland
other interventions can protect children from the negative can improve children’s cognitive and social–emotional
(M Cabral de Mello PsyD);
consequences of living in poverty. International Food Policy
development and school readiness. Research Institute,
• Quality in early child development programmes can be Washington, DC, USA
Inequalities between and within countries maximised through design, curriculum, practise for (M Hidrobo PhD); United
Social and economic differences, both between and within parents, training for childcare workers, monitoring and
Nations Children’s Fund,
New York, NY, USA
countries, contribute to inequalities in children’s assessment, governance, and supervision. (N Ulkuer PhD); Department
development. The WHO Commission on the Social • Increasing preschool enrolment to 25% or 50% in each of Pediatrics, Faculty of
Determinants of Health, in a World Health Assembly low-income and middle-income country would result in a Medicine, University of
report,5 highlighted the social injustice of “avoidable health benefit-to-cost ratio ranging from 6·4 to 17·6 depending
Ankara, Ankara, Turkey
(Prof I Ertem PhD); and
inequalities” and concluded that social and economic on preschool enrolment rate and discount rate. Bernard van Leer Foundation,
policies addressing early child development can affect • Unless governments allocate more resources to quality The Hague, Netherlands
whether children develop to their potential or experience a early child development programmes for the poorest (S Iltus PhD)
constrained life-course trajectory. Not only are there major people in the population, economic disparities will
differences between countries in preschool attendance by continue and widen.
gross national income (GNI), but also within countries.
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Educa tu Hijo (Educate your Child) was adapted from
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Cuba’s model, which combines health care with a
ica
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by the health sector and community committees. Figure 1: Proportion of young children attending preschool in 58 low-income and middle-income
Children in the programme had higher cognitive scores countries by income quintile within country summed across sample countries by region (A) and by
than those not in the programme.23 country in Latin America (B)
(A) Data are from the UNICEF’s 2005 Multiple Indicator Cluster Survey 3 for children aged 3 and 4 years. Countries
In central Asia, the assessment of the implementation included in each region are Albania, Belarus, Bosnia and Herzegovina, Georgia, Kazakhstan, Kyrgyzstan, Macedonia,
of the Care for Development module of Integrated Serbia, Tajikistan, Ukraine, Uzbekistan (central and eastern Europe, CIS, and Baltic states); Bangladesh (south Asia);
Management of Childhood Illness noted that children’s Laos, Mongolia, Thailand, Vanuatu, Vietnam (east Asia and Pacific); Belize, Guyana, Jamaica, Suriname, Trinidad
developmental scores were substantially higher in and Tobago (Caribbean); Burkina Faso, Burundi, Cameroon, Central African Republic, Côte d’Ivoire, Djibouti,
Gambia, Ghana, Guinea-Bissau, Malawi, Mauritania, Nigeria, Sierra Leone, Somalia, Togo (sub-Saharan Africa); Iraq,
intervention districts than in similar control districts. Lebanon, Syria, Yemen (Middle East). (B) Adapted from Vegas and Santibanez,6 with permission. The rates in
There were also improvements in parents’ activities with Argentina, El Salvador, Honduras, Peru, and Venezuela are for children aged 3–6 years; in Bolivia, Colombia, Costa
children and in health-worker recommendations.26 The Rica, Mexico, Panama, and Paraguay for children aged 5–6 years; and in the Dominican Republic and Nicaragua are
Care for Development module, developed by WHO and for children aged 4–6 years. In all other countries the rates are for children aged 0–6 years. Income quintiles are
calculated within country and summed across regional areas. CIS=Commonwealth of Independent States.
UNICEF, trains health workers to provide specific
behavioural recommendations to caregivers about play,
communication, and responsive feeding.31 Two effective- duration did not necessarily result in better outcomes. A For the data from the Multiple
ness studies (reported above) also assessed the Care for meta-analysis of US programmes, for example, identified Indicator Cluster Survey see
http://www.childinfo.org
Development module and identified substantial effects that an intervention including only 16 effective, high-
on home stimulation20 and child development.18 In quality sessions showed substantial effects on parent–
general, parenting programmes that were more effective child interactions.35
had a well developed parenting curriculum, adequate Although many low-income and middle-income
training of workers, a balance of health, nutrition, and countries have put child development messages on
early child development components, and both com- child health cards, growth charts, and so-called baby
munity and governmental (local or national) support.23 passports, there were few assessments of their
In high-income countries,32 three meta-analyses of effectiveness in low-income and middle-income
parenting and home visiting programmes32–34 identified countries. In one study in India, literate parents who
similar factors contributing to programme effectiveness: kept a card with Care for Development messages for
systematic curricula, training for workers and parent 2 months increased their recall, understanding, and
educators, and active strategies to promote caregiver reported appreciation of these messages.36
behaviour change, such as feedback, coaching, roleplay,
and videotaped interactions. They also noted that the Preschool, childcare centres, and daycare
quality of the relationship between parent and worker We also assessed effects of two preschool models: formal
was positively correlated with effectiveness.32,33,34 Long pre-primary or preschool programmes—generally linked
6·0 Poorest
Second no studies were identified that assessed the effect of
5·0 Middle
Fourth
daycare—the provision of full daycare for infants and
4·0 Richest young children of employed caregivers, which vary from
3·0
offering only custodial care to educational care.
15 assessments (10 effectiveness studies and five
2·0
programme assessments) met the relevant inclusion
1·0 criteria (table 2 and webappendix pp 7–15). Nine studies,37–50
0
including five programme assessments, compared
preschool attendees with non-attendees, controlling for
B initial differences. In eight, attendees had higher scores on
6·0 one or more measures of child development, such as
Mean father activities (in past 3 days)
Standard score
0·14
popular approach to long-term poverty alleviation;55,56
0·04
the expectation of conditional cash transfer programmes 0
–0·03
–0·09 –0·07
is that families use cash transfers both to help parents –0·19
–0·2 –0·23
provide for their children’s needs and as an incentive –0·25
–0·32 –0·34 –0·33
for parents to invest in their children’s health –0·4
and education.57–59 –0·46
Many conditional cash transfer programmes distribute –0·6
benefits conditional on mandatory attendance at
preventive health-care services and health and nutrition –0·8 –0·83
education sessions designed to promote positive
behavioural changes, and some programmes also –1·0
require school attendance for children of school age. Ethiopia India Peru Vietnam
Whether conditionality makes a difference in the (Amarigna) (Telugu) (Spanish) (Vietnamese)
Design details in webappendix pp 1–6. If effect sizes were not reported we calculated a Cohen’s d (d) effect sizes from either post-test means, differences from pretest to post-test means, or from ordinary least
squares regression results. We focused on main effects and not subgroups, unless results were only presented by subgroups. If results were only presented by subgroups, then we reported the range of the effect
size. We also reported the range for tests that had subscales. If studies did not report Cohen’s d effect sizes, and we did not have the information to calculate them, then we reported unavailable. HOME=Home
Observation for Measurement of the Environment.29
Table 1: Summary of interventions and effect sizes for 15 studies of parenting education programmes, support programmes, or both, comparing interventions with standard of care
disabilities, severe acute malnutrition, being small for development with effects lasting into childhood and
gestational age and low birthweight (LBW), and being adult years.78–81 In Jamaica, weekly home visits for LBW
infected with HIV/AIDS (webappendix pp 18–20). term infants resulted in higher development quotients
at 6 years.82 In India, mothers of at-risk infants
Children with developmental disabilities (75% LBW, premature, or both) were randomly assigned
Few studies have assessed intervention models for children to receive training to provide stimulation at home over
with disabilities in low-income and middle-income 12 months. At both 12 months and 2 years, intervention
countries. One randomised clinical trial in Bangladesh children’s cognitive development was greater.83 Ongoing
reported that rural children with disabilities whose work in India, Pakistan, and Zambia will provide more
caregivers received a parenting training package progressed data on early stimulation for at-risk infants in
more on adaptive skills and that the mothers improved in community-based settings.84
their support for their children, compared with a minimal
intervention.72 Community-based rehabilitation, a strategy Children affected and infected by HIV/AIDS
advocated by WHO, is widely used but not well assessed— Young children in communities affected by the AIDS
a review of 128 published studies identified few robust pandemic are exposed to many threats. Even though
assessments.73 Studies recommend broader community fewer young children are becoming infected because of
awareness and more evidence, more screening and referral the increase in programmes for the prevention of
services, and caregiver support.72,74 mother-to-child transmission, the overall number of
vulnerable and infected children, particularly in sub-
Children with severe acute malnutrition Saharan Africa, is high.85 Interventions to improve early
WHO recommends incorporating stimulation into child development for these children include support-
management strategies for children with malnutrition, in ing caregivers’ capacity through home visits, cash
addition to food supplementation and health care,75 but transfer systems (eg, so-called child grants in South
we identified few studies testing the effects of such inte- Africa), preschool programmes, and legal protection
grated programmes. One study in Bangladesh76 and one strategies.70,86 In a randomised controlled trial, a home
in Uganda77 showed positive effects of stimulation on early stimulation programme provided to caregivers of infants
child development for severely malnourished children. infected with HIV at clinic visits every 3 months resulted
in substantially higher cognitive scores at 12 months.87
Children small for gestational age or LBW Many qualitative or pre-test and post-test design
Early interventions for LBW infants in high-income studies have shown benefits of these programmes on
countries improve cognitive and social–emotional the child-rearing behaviours of caregivers, and on
Design details in webappendix pp 7–15. If effect sizes were not reported we calculated a Cohen’s d (d) effect sizes from either post-test means, differences from pretest to post-test means, or from ordinary least
squares regression results. We focused on main effects and not subgroups, unless results were only presented by subgroups. If results were only presented by subgroups, then we reported the range of the effect
size. We also reported the range for tests that had subscales. If studies did not report Cohen’s d effect sizes, and we did not have the information to calculate them, then we reported unavailable.
Table 2: Summary of interventions and effect sizes for 15 studies with preschool programmes, preschool-improvement programmes, or both
preschool attendance88,89 and early child development,87,89 publicly funded childcare centres exist in 86% of villages,
but there is a need for more robust assessments.86 but coverage reaches only 39% of the age-eligible
population.90 A recent estimate of the cost of scaling up
Programmatic implications nutrition services noted that the unit costs were constant
Most effectiveness studies that we have reviewed reported for 80% of the population, but were 3–4-times higher for
substantial and positive effects on child development, the next 10%.93,94 Yet to reduce inequality, investments
but results from assessments of scaled-up programmes must be targeted at the poorest. Our review suggests that
were more variable. In panel 3 we list our conclusions effects might be greater for these children, possibly
and recommendations for the scale-up of early child resulting in a more favourable benefit-to-cost ratio.
development programmes. The Wolfensohn Center at Countries might have difficulty creating a mechanism
Brookings Institution assessed issues in taking early for integrated or coordinated interventions for early child
child development to scale from 2005 to 2011.23,90,91 development across sectors.90 A programme is often run
Expanding coverage while maintaining quality is a major by one ministry and coordination with others can be
issue for every programme, and needs a system of limited, even if the effects could be synergistic. Community
capacity development.92 Scale-up efforts in Mexico and involvement and the demand for services as well as a legal
South Africa have identified that existing systems, policy structure have facilitated implementation.23,90–92 In
including private ones, might be undermined when the Philippines, for example, a legal mandate combined
public coverage expands.91,92 Scale-up to universal several delivery systems with local government control to
provision should include systems of governance, create an integrated programme.90 Under a controlled
provisioning, and capacity building for implementation, political system, Cuba’s Educa Tu Hijo programme
and must include ongoing and continual advocacy.91 effectively scaled up an integrated approach and achieved
Monitoring methods are needed to track progress and virtually universal coverage of young children in early
facilitate advocacy. child development by 2000.23 Community involvement
Co-occurring risk factors such as stunting and lack of and ownership were important for its successful scale-up.
stimulation should be addressed together for maximum For most programmes, early child development
effect, such as combining nutrition, responsive child components for younger children (aged 0–3 years) were
feeding, and child-stimulation interventions.14,15 Few less common than for older children. Incorporating early
studies have assessed which combinations work best, child development activities into the health system—
although several combinations exist. Combinations tend through prenatal care, breastfeeding promotion pro-
to be more effective if addressing risks that co-occur, and grammes, wellchild visits, consultations for mild illnesses,
if the programme can coordinate interventions to parenting education, and early intervention for at-risk
minimise extra work. Adding early child development children—might provide the best opportunities for
might be motivating for parents and childcare workers. reaching children younger than 3 years.
Research is urgently needed on how to effectively integrate
psychosocial interventions with programmes to address Estimating potential benefits of preschool
the risks identified in the first report of this Series.4 Preschool is only one component of a comprehensive
Reaching the poorest, a key goal for many programmes, early child development agenda, but can serve as a proxy
is also a challenge. In the Philippines for example, in an analysis of potential economic benefits of increasing
Panel 3: Recommendations for development and expansion of national programmes Panel 4: Methods for our gap analysis
to support early child development
We estimated the association between the schooling gap
Maximise quality of early child development programmes (gap in median years of schooling between the wealthiest
• Maximise quality in all early child development programmes, in programme design, quintile and each of the other quintiles) and preschool
curriculum, childcare-provider development, monitoring and assessment, and enrolment by regressing the gap on the preschool gross
governance and supervision enrolment rate 8–12 years earlier for each country with
• Adapt programmes to children and families from ethnically or economically ordinary least squares in Stata 10, controlling for per head
vulnerable groups gross domestic product (GDP) in constant dollars adjusted for
• Incorporate families and communities as active partners in the development of early purchasing power and income inequality (by use of the Gini
child development programmes to integrate relevant child-rearing practices and coefficient). We then calculated the projected economic gain
cultural beliefs from decreasing the schooling gap through increasing
Promote multisectoral integration preschool enrolment as the present discounted value of
• Mainstream early child development into health programmes such as maternal and added wage productivity. We estimated added wage
child health; nutrition; HIV/AIDS, malaria, and tuberculosis; mental health; violence; productivity for each country using a weighted average of
and injury 8·3% for urban areas and 7·5% for rural areas for the returns
• Develop effective coordination mechanisms in sectors for early child development to an additional year of schooling,93 and average wages were
• Develop and assess integrated strategies, packages, and approaches to early child based on a 40% wage share of GDP. We used discount rates of
development that are suitable for scale-up 3% and 6% to adjust (to the time at which investments in
preschool enrolments are assumed to be made) future wage
Prioritise monitoring and assessment earnings starting 12 years after preschool enrolment and
• Systematically assess effectiveness of early child development interventions to lasting 45 years. We estimated the economic benefits from
establish the most effective approaches to improve quality and outcomes particularly increasing preschool programmes under three scenarios:
for the most disadvantaged moving countries with less than 25% pre-primary enrolment
• Assess relative effectiveness of various quality improvements for preschools to 25%, moving countries with less than 35% pre-primary
(eg, adding more years of preschool, increasing teacher training) enrolment to 35%, and moving countries with less than 50%
• Develop and assess cost-effectiveness of new approaches for early child development pre-primary enrolment to 50%.
promotion such as conditional cash transfer programmes with an early child
In table 3 we summarise these estimates for one cohort of
development component, educational media, or other information technologies for
children in 2008 US$. Changes in preschool enrolments are
children and families and integrated programmes
simulated to induce reductions in schooling gaps based on
• Assess the relative effectiveness of early child development interventions for children
the regression analysis discussed.
at risk because of malnutrition, low birthweight, HIV, or disabilities
Emphasise policy action
• Use the existing theory and evidence to inform policy and decision makers at all country fixed-effects and inclusion of child mortality rate
levels that early child development is fundamental to the promotion of social as a control provide some assurance that the results are
justice and equity attributable to preschool enrolment, rather than the
• Build a sustainable funding mechanism for early child development services and access or quality of the school and health systems.
interventions We calculated the loss in dollars from the schooling gap
• Acknowledge and support interventions that protect and support children and and identified that the gaps between the richest quintile
families in the first 5 years of life and the poorer quintiles within low-income and middle-
income countries resulted in an estimated total loss of
$196 billion in present annual productivity due to fewer
investments. We estimated the effect of preschool years of schooling (panel 4). Using estimates from the
enrolment on the gap between schooling attainment of regression of the schooling gap on preschool enrolment,
the wealthiest quintile of youth (aged 15–19 years) we then simulated reductions in schooling gaps due to
compared with youth in the other wealth quintiles for increasing preschool enrolment rates and calculated the
73 low-income and middle-income countries with a total economic benefits of reducing the schooling gap for one
population of 2·69 billion people (panel 4).98 Our cohort of children.
estimates show that for every percentage point increase With a 3% discount rate, the benefits from reducing the
in preschool enrolment, the schooling gap for those aged schooling gap range from $10·6 billion with an increase
15–19 years declines 0·026 grades (95% CI –0·14 to –0·38; of all children in each country to 25% enrolment for 1 year
figure 4). This result, which controls for a country’s gross of preschool, to $33·7 billion with an increase to
domestic product (GDP) and inequality rates (as 50% preschool enrolment (table 3). With a 6% discount
measured by the Gini index) is robust to the use of rate the benefits were $4·7 billion (for 25%) to $14·9 billion
country fixed-effects for countries where two or more (for 50%). These benefits, compared with the costs based
observations were available, and to the inclusion of child on the number of additional children enrolled and the
mortality in the fixed-effects regressions. The use of median cost of preschool per student,99 imply benefit-to-
cost ratios respectively from 6·4 to 17·6, and are similar to only preschool enrolment, and do not include parenting,
programme-specific estimates100 for the USA,101 Turkey,102 nutrition and health programmes, which are also known
and Uruguay (panel 5).41 to improve the child’s school performance and therefore
Our estimates, based on several assumptions, suggest have economic benefits. Increased earnings are calculated
substantial potential gains from increasing preschool assuming that GDP is not growing over time with
attendance with very satisfactory benefit-to-cost ratios. technological change or increased capital investment; the
The estimates are most likely conservative because they resulting benefits would be larger if these were included.
include only direct wage productivity benefits and many
studies suggest that there would be additional benefits Trends in policies and funding
due to increased schooling, such as reduced crime and In the 2007 Series, there was a call for expanded early
improved parenting. Additionally, the estimates include child development programmes, policies, and coord-
inating mechanisms at the national level. According to
UNICEF annual reports, more than 40 countries are
6 developing or have developed and received parliamentary
approval for early child development policies, and several
Average education gap (years)
Our sample consists of 73 countries with a population of about 3 billion with preschool data from 1998–2007. We dropped Bangladesh, Namibia, and Tanzania from our
sample because of inconsistent statistics in the preschool enrolment rates. The schooling gap is the gap in median years of schooling between the wealthiest quintile and
each of the other quintiles for individuals 15–19 years old.95 The benefits due to increasing enrolment were calculated with estimates from an ordinary least squares (OLS)
regression of average schooling gap on preschool enrolment from 8 to 12 years before the schooling gap statistic,96 gross domestic product per capita, and Gini.97 Estimates
from OLS regression were used to simulate the schooling gap under three scenarios with preschool enrolment floors of 25%, 35%, and 50%. The economic benefit from
decreasing the schooling gap through increasing preschool enrolment was calculated as the present discounted value (PDV) of added wage productivity under the
assumption that earnings are zero for first 12 years after preschool and then are equal to yearly average earnings incremented by the average rates of return to schooling for
the subsequent 45 years. For the benefit-to-cost ratio, we used the median cost per preschool student in 2004 from UNESCO data on 38 low-income and middle-income
countries (US$77·50) adjusted to show the 2008 values ($88·34).
opportunities for parental practice with children with 5 Commission on Social Determinants of Health. Closing the gap
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were more consistently effective. Promising interventions Latin America and the Caribbean. Washington, DC: The World
Bank, 2010.
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conditional cash transfer programmes and developing Imágenes Peabody (Peabody Picture Vocabulary Test): Adaptación
educational media for children and parents. There is Hispanoamericana (Hispanic-American Adaptation). Circle Pines,
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our review and economic simulation, we conclude that optimize early childhood development in low resource settings.
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early child development interventions are a good 12 McMaster University School of Nursing. Effective public health
investment for reducing inequalities in the development practice project: quality assessment tool for quantitative studies.
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Contributors program evaluation standards: a guide for evaluators and evaluation
All authors participated in the review of published work, and drafting users, 3rd edn. Thousand Oaks, CA: Sage, 2011.
and review of the report. PLE and LCHF are the lead authors. All authors 14 Aboud FE, Akhter S. A cluster-randomized evaluation of a
reviewed and provided commentary on the text. Reviews and drafting of responsive stimulation and feeding intervention in Bangladesh.
individual topics were as follows: economic issues HA, JB, and MH; Pediatrics 2011; 127: e1191–97.
parenting PLE and LCHF; preschool CO’G, LCHF, and PLE; media PLE; 15 Bentley ME, Vazir S, Engle PL, et al. A home-based educational
conditional cash transfers LCHF; disabilities and high-risk AY and IE; intervention to caregivers in south India to improve complementary
political and social context MCdeM, NU, and SI. The steering committee feeding and responsive feeding, and psychosocial stimulation
increases dietary intake, growth and development of infants.
of the Global Child Development Group coordinated the writing of the For more on the Global Child
FASEB J 2010; 24 (suppl): 564.14.
report in this Series. Development Group see http://
16 Cooper PJ, Tomlinson M, Swartz L, et al. Improving quality
www.globalchilddevelopment.org
Conflicts of interest of mother-infant relationship and infant attachment in
We declare that we have no conflicts of interest. socioeconomically deprived community in South Africa:
randomised controlled trial. BMJ 2009; 338: b974.
Acknowledgments
17 Klein PS, Rye H. Interaction-oriented early intervention in Ethiopia:
We thank Kallista Bley for help in document preparation, Santiago Cueto the MISC approach. Infants and Young Children 2004; 17: 340–54.
for Young Lives data, Ivelina Borisova for document searches and 18 Jin X, Sun Y, Jiang F, Ma J, Morgan C, Shen X. “Care for
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Susan Walker, Ted Wachs, Maureen Black) have reviewed all drafts 19 Leung C, Sanders MR, Leung Sl, Mak R, Lau J. An outcome
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