A Review of the Height and Weight of Children Around the World Concluded That There Are

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Lancet. 2007 Jan half-dozen; 369(9555): 60–seventy.

Developmental potential in the first 5 years for children in developing countries

Sally Grantham-McGregor

^aCentre for International Child Health, Plant of Child Health, University College London, United kingdom of great britain and northern ireland

Yin Bun Cheung

^bLondon Schoolhouse of Tropical Medicine and Hygiene, U.k.

Santiago Cueto

^cGroup for the Analyses of Development, Lima, Republic of peru

Paul Glewwe

^dDepartment of Applied Economics, University of Minnesota, USA

Linda Richter

^eHomo Sciences Research Council, S Africa

Barbara Strupp

^fDivision of Nutritional Sciences and Section of Psychology, Cornell Academy, USA

Supplementary Materials

Webtable Achievement in reading for sixth grade students in 12 African countries

GUID: 31897C63-9D41-4EA5-8E64-0258A4BA09BA

Webappendix

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Summary

Many children younger than v years in developing countries are exposed to multiple risks, including poverty, malnutrition, poor wellness, and unstimulating home environments, which detrimentally impact their cerebral, motor, and social-emotional development. There are few national statistics on the development of young children in developing countries. We therefore identified ii factors with available worldwide data—the prevalence of early on childhood stunting and the number of people living in absolute poverty—to use as indicators of poor evolution. Nosotros testify that both indicators are closely associated with poor cognitive and educational functioning in children and utilise them to approximate that over 200 million children nether v years are not fulfilling their developmental potential. Nearly of these children live in south asia and sub-Saharan Africa. These disadvantaged children are likely to practice poorly in school and subsequently have low incomes, high fertility, and provide poor care for their children, thus contributing to the intergenerational transmission of poverty.

*Atomic number 82 authors

†Steering grouping listed at stop of the paper

This is the start in a Serial of three articles about child development in developing countries

Introduction

A previous Lancet series¹ focused attending on the more than 6 million preventable kid deaths every year in developing countries. Unfortunately, decease is the tip of the iceberg. We have made a conservative estimate that more than 200 million children under 5 years fail to reach their potential in cognitive evolution because of poverty, poor health and nutrition, and deficient care. Children'south development consists of several interdependent domains, including sensory-motor, cognitive, and social-emotional, all of which are probable to exist afflicted. Withal, we focus on cognitive development because of the paucity of data from developing countries on other domains of young children'due south development. The discrepancy between their current developmental levels and what they would have achieved in a more than nurturing environment with adequate stimulation and nutrition indicates the degree of loss of potential. In later childhood these children will afterward take poor levels of knowledge and educational activity, both of which are linked to later earnings. Furthermore, improved parental education, especially of mothers, is related to reduced fertility,^2,3 and improved child survival, health, nutrition, cognition, and education.^3–vii Thus the failure of children to fulfil their developmental potential and accomplish satisfactory educational levels plays an important part in the intergenerational transmission of poverty. In countries with a large proportion of such children, national development is likely to be affected.

The commencement Un Millennium Evolution Goal is to eradicate farthermost poverty and hunger, and the second is to ensure that all children complete principal schooling.^eight Improving early on child development is clearly an important step to reaching these goals. Although policymakers recognise that poverty and malnutrition are related to poor health and increased mortality,^5,9 in that location is less recognition of their issue on children'due south development or of the value of early intervention. This paper is the first of a three part series reviewing the trouble of loss of developmental potential in immature children in developing countries. The get-go paper describes the size of the issue, the second newspaper discusses the proximal causes of the loss, and the final paper reviews existing interventions. Here, nosotros first examine why early kid development is of import and so develop a method to gauge the numbers of children who fail to fulfil their developmental potential. We then estimate the loss of income attributed to poor child development.

Why early kid development is important

Children's development is afflicted by psychosocial and biological factors^x and past genetic inheritance. Poverty and its attendant problems are major gamble factors.^11–fifteen The first few years of life are particularly important because vital development occurs in all domains.¹⁶ The brain develops rapidly through neurogenesis, axonal and dendritic growth, synaptogenesis, cell death, synaptic pruning, myelination, and gliogenesis. These ontogenetic events happen at different times (figure 1)¹⁷ and build on each other, such that minor perturbations in these processes tin have long-term furnishings on the brain'due south structural and functional capacity.

Human being brain development

Reproduced with permission of authors and American Psychological Association¹⁷ (Thompson RA, Nelson CA. Developmental science and the media: early encephalon evolution. Am Psychol 2001; 56: 5–fifteen).

Brain development is modified by the quality of the environment. Brute research shows that early undernutrition, fe-deficiency, ecology toxins, stress, and poor stimulation and social interaction can affect brain structure and office, and have lasting cognitive and emotional effects.^18–24

In humans and animals, variations in the quality of maternal care can produce lasting changes in stress reactivity,²⁵ anxiety, and retention function in the offspring,

Despite the vulnerability of the brain to early insults, remarkable recovery is often possible with interventions,^18,26,27 and more often than not the earlier the interventions the greater the benefit.²⁸

Early cerebral development predicts schooling

Early cognitive and social-emotional development are potent determinants of school progress in developed countries.^29–31 A search of databases for longitudinal studies in developing countries that linked early kid development and subsequently educational progress identified two studies. In Guatemala, preschool cerebral ability predicted children's enrolment in secondary school³² and accomplishment scores in boyhood.³³ In Southward Africa, cognitive power and achievement at the end of grade i predicted later school progress.³⁴ Three further studies had appropriate data that we analysed (from the Philippines^35,36 and Jamaica³⁷) or requested the investigators to analyse (from Brazil^38,39). In each instance, multiple regression of educational outcome (or logistic regression for dichotomous variables), controlling for a wealth index,^xl maternal education, and child's sex activity and historic period, showed that early cognitive development predicted afterward schoolhouse outcomes. Table 1 shows that each SD increase in early intelligence or developmental quotient was associated with essentially improved school outcomes. Farther evidence of the importance of early babyhood is that interventions at this historic period^37,41 tin take sustained cognitive and school achievement benefits (table ane ^35–39).

Table 1

Change in later school outcomes per SD increase in intelligence quotient (IQ) or developmental quotient (DQ) in early life^*

	N	Independent variable	Outcome variable	Measure of consequence	Estimate	95% CI
Jamaica†	165	IQ on the Stanford Binet exam (42) at seven years	Dropped out before grade 11	Odds ratio	0·53‡	0·32–0·87
			Reading and arithmetics score at age 17	Mean difference in SD	0·65§	0·53–0·78
Philippines	1134	Cerebral Score at 8 years	Always echo a grade past age 14 years	Odds ratio	0·lx¶	0·49–0·75
Brazil‖	152	DQ on Griffiths test (43) at iv.5 years	Grades attained by age 18 years	Mean difference in grades achieved	0·71**	0·34–i·07

Problem of poor development

National statistics on young children's cerebral or social-emotional development are non available for most developing countries, and this gap contributes to the invisibility of the problem of poor evolution. Failure to complete primary didactics (Millennium Development Goal 2) gives some indication of the extent of the issue, although schoolhouse and family unit characteristics also play a function. In developing countries, an estimated 99 million children of primary-school age are not enrolled, and of those enrolled, but 78% consummate chief school.⁴⁴ Most children who fail to consummate are from sub-Saharan Africa and due south Asia. Just around one-half of the children enrol in secondary schools. Furthermore, children in some developing countries have much lower accomplishment levels than children in developed countries in the same grade.⁴⁵ In 12 African countries, surveys of form 6 (stop of principal school) children showed that on average 57% had not achieved minimum reading levels (webtable).^46–57

Indicators of poor evolution

In the post-obit section we guess the numbers of children who fail to reach their developmental potential. We first identify early childhood growth retardation (length-for-age less than −2 SD according to the National Eye for Wellness Statistics growth reference⁵⁸ [moderate or severe stunting]) and absolute poverty as possible indicators for poor evolution. We and then evidence that they are skillful predictors of poor school accomplishment and cognition. Finally, we employ these indicators to gauge the number of children involved. We identified stunting and poverty for indicators because they stand for multiple biological and psychosocial risks, respectively, stunting and to a bottom extent poverty are consistently defined beyond countries, both are relevant to nearly developing countries, and worldwide data are available. We omit other risk factors that could affect children'due south development because they neglect to fit all the above criteria and there is marked overlap betwixt them and with stunting and poverty. However, by using just two risk factors we recognise that our estimate is conservative.

Cess of stunting, poverty, and kid development

Growth potential in preschool children is similar across countries,^{59,threescore} and stunting in early on babyhood is caused past poor nutrition and infection rather than by genetic differences. Patterns of growth retardation are as well similar across countries.⁶¹ Unpleasing begins in utero or soon after birth, is pronounced in the first 12–18 months,⁶² and could keep to effectually 40 months, afterwards which it levels off. Some catch-upward might take identify,⁶³ only most stunted children remain stunted through to adulthood.

There are multiple approaches to measuring poverty.⁶⁴ One cess used measures of deprivation of bones needs, availability of services, and infrastructure,⁶⁵ and surveys in 45 developing countries reported that 37 % of children lived in absolute poverty, more than so in rural areas. We use the percentage of people having an income of less than The states$1 per 24-hour interval, adjusted for purchasing power parity by country⁶⁶ because this information is available for the largest number of countries. This indicator is considered the all-time available despite excluding important components of poverty,⁶⁷ and is more conservative than measures based on deprivation⁶⁵ since it identifies only the very poorest families.

Poverty is associated with inadequate nutrient, and poor sanitation and hygiene that pb to increased infections and stunting in children. Poverty is too associated with poor maternal education, increased maternal stress and depression,^12,68,69 and inadequate stimulation in the home.⁷⁰ All these factors detrimentally affect child development (figure 2).^12,seventy Poor development on enrolment leads to poor school achievement, which is further exacerbated past inadequate schools and poor family support (due to economic stress, and trivial cognition and appreciation of the benefits of instruction).

Hypothesised relations between poverty, stunting, child development, and schoolhouse achievement

Gamble factors related to poverty oftentimes occur together, and the developmental deficit increases with the number of take chances factors.^15,33,71 Deficits in evolution are often seen in infancy^31,72 and increment with age.^71,73,74 For example, a cross sectional study in Ecuador reported that the linguistic communication arrears in poor children increased from 36 to 72 months of historic period compared with wealthier children (figure iii).^seventy

Vocabulary scores of Ecuadorian children aged 36 to 72 months past wealth quartiles

TVIP=Exam de Vacabulario en Imagenes Peabody. Reproduced with permission from the authors.⁷⁰

As a first pace to examining the use of poverty and stunting as indicators, we did regression analyses of the relation between the percentage of children completing primary school⁴⁴ and poverty and stunting, with data from developing countries (defined as the not-industrialised countries in UNICEF nomenclature).⁷⁵ Stunting prevalence was based on the WHO Global Database on Child Growth and Malnutrition,⁷⁶ and accented poverty prevalence came from UNICEF.⁷⁵ In 79 countries with information on stunting and instruction, the average prevalence of stunting was 26·0%. For every 10% increase in stunting (less than −2 SD), the proportion of children reaching the final form of primary school dropped past 7·9% (b=−0·79, 95% CI −ane·03 to −0·55, Rⁱⁱ=36·two%, p<0·0001). In 64 countries with information on absolute poverty, the boilerplate prevalence was 20%; for every 10% increase in the prevalence of poverty there was a subtract of 6·iv% (b=−0·64, 95% CI=−0·81 to −0·46, R²=46·3%, p<0·0001) of children entering the terminal grade of primary school.

To establish whether stunting and accented poverty were useful predictors of poor child development in individual studies, nosotros searched the published papers and identified all observational studies that related stunting and poverty in early childhood to concurrent or afterward kid development or educational outcomes. We as well identified all studies that related stunting at school age to cognition or education, based on the assumption that stunting developed in early childhood. We selectively reviewed studies of older children that linked economical status to school achievement or knowledge, choosing examples with international or nationally representative samples. We assessed whether measurements of the take a chance factors and developmental result were clearly reported, and the relation between them (adapted or unadjusted) was examined. We did non assess causality.

Stunting and poor development

Cross-sectional studies

Many cross-exclusive studies of high-risk children have noted associations between concurrent stunting and poor schoolhouse progress or cognitive ability. Stunted children, compared with non-stunted children, were less probable to be enrolled in schoolhouse (Tanzania⁷⁷), more likely to enrol tardily (eg, Nepal,⁷⁸ and Republic of ghana and Tanzania⁷⁹), to attain lower achievement levels or grades for their age (Nepal,⁷⁸ China,⁸⁰ Jamaica,^81,82 India,⁸³ Philippines,^84–86 Malaysia,⁸⁷ Vietnam,⁸⁸ Brazil,⁸⁹ Turkey,^xc Guatemala [just in boys]⁹¹), and accept poorer cognitive ability or accomplishment scores (Kenya,⁹² Republic of guatemala,⁹³ Indonesia,⁹⁴ Ethiopia, Peru, Republic of india, and Vietnam,⁹⁵ and Chile⁹⁶). Only three studies^97–99 reported no significant relation between stunting and poor school progress. In the Philippines, associations were recorded with weight-for-top,⁹⁹ and in Ghana⁹⁸ stunted children enrolled in school late but taller children left school early to earn money or assist with family farming.

At that place are fewer studies with younger children. In Guatemala,¹⁰⁰ Jamaica,¹⁰¹ Republic of chile,¹⁰² and Kenya,¹⁰³ associations between top and child development measures were reported. Historic period of walking was related to height-for-age in Zanzibarian¹⁰⁴ and Nepalese children,¹⁰⁵ but meridian was non related to motor development in Kenyans at 6 months of age.¹⁰⁶ Weight-for-age, which indicates a combination of weight-for-height and height-for-age, has ofttimes been used instead of stunting to measure nutrition in young children. Weight-for-age was associated with child development in India,¹⁰⁷ Federal democratic republic of ethiopia,¹⁰⁸ and Bangladesh.^109,110

Longitudinal studies

In Pakistan¹¹¹ and Guatemala,¹¹² growth retardation in infancy predicted age of walking. Excluding studies of children hospitalised for astringent malnutrition, four published longitudinal studies showed that early stunting predicted later knowledge, school progress, or both. Stunting at 24 months was related to cognition at 9 years in Republic of peru¹¹³ and, in the Philippines to intelligent caliber (IQ) at 8 and xi years, historic period at enrolment in school, form repetition, and dropout from school.^35,36 In Jamaica, stunting before 24 months was related to noesis and school achievement at 17–18 years and dropout from school.³⁷ In Guatemala, height at 36 months was related to knowledge, literacy, numeracy, and general knowledge in late adolescence,¹¹⁴ and stunting at 72 months was related to cognition between 25–42 years.¹¹⁵ In Indonesia,¹¹⁶ weight-for-historic period at 1 yr of age did not predict scores on a cognitive test at seven years, whereas growth in weight between 1 and 7 years did.

To assess the size of the deficit in later part associated with a loss of i SD in height in early on childhood, we reanalysed the data from Philippines,³⁶ Jamaica, ³⁷ Peru,¹¹³ and Republic of indonesia ¹¹⁶ (Guatemala had likewise few well-nourished children to be included). We added ii other longitudinal studies, from Brazil³⁸ and Due south Africa,¹¹⁷ that had not previously analysed the effect of stunting (table 2). In these studies, stunting betwixt 12 and 36 months was related to later measures of cognition¹¹⁷ or grade attainment.³⁸ Beingness moderately or severely stunted compared with non stunted (height-for-age greater than −1 SD) was associated with scores for cognition in every written report, and the effect size varied from 0·four to i·05 SD. Stunting was also associated with attained grades. The consistent relation between early on childhood stunting and poor child development, with moderate to large effects, justifies its use as an indicator of poor evolution.

Tabular array 2

Descriptive summary of follow-up studies showing associations betwixt stunting in early childhood and later scores on cognitive tests and school outcomes

	Philippines	South Africa	Indonesia	Brazil *	Republic of peru	Jamaica †
	Cerebral score (eight years, n=2489)	Ravens Matrices120 (7 years, due north=603)‡	Reasoning and arithmetic (ix years, n=368)	Attained grades (xviii years, n=2041)	WISC IQ119 (9 years, northward=72)	WAIS IQ‡ 118 (17–18 years, n=165)	Reading and arithmetic‡ (17–18 years)
Not stunted	56·4	0·17	xi·2	eight·ane	92·3	0·38	0·40
Mildly stunted	53·eight (−0·21)	0·05 (−0·12)	ten·3 (−0·26)	7·2 (−0·four)	89·8 (−0·20)
Moderately or severely stunted	49·6 (−0·54)	−0·23 (−0·40)	9·vii (−0·43)	half dozen·v (−0·vii)	79·2 (−1·05)	−0·55 (−0·93)	−0·lx (−1·00)

Poverty and poor evolution

Cross-sectional studies

Nationally representative studies from many countries have seen relations between household wealth and school enrolment, early dropout, grades attained, and achievement.^{46–57,95,121–123} Gaps in mean attained grades betwixt the richest and poorest children were specially large in western and central Africa and s Asia, reaching equally high as ten grades in India.¹²³ In Zambia, poor children were four times more than likely to first school late than the richest children, and in Uganda the divergence was ten times. Representative surveys in 16 Latin American countries¹²⁴ likewise reported that family income predicted the probability of completing secondary schooling. Rural children were worse off in nearly studies.¹²³

There are fewer studies on wealth and evolution in preschool children. In 3668 Indian children under vi years, paternal occupation was associated with developmental milestones.¹⁰⁷ In Ecuador, wealth was related to vocabulary scores of children from 3 to half-dozen years of historic period.^seventy In Jamaica, 71·4% of 3887 children from more flush families entering fee-paying preparatory schools had mastery of all 4 school-readiness subjects tested, compared with 42·7% of 22 241 children entering free regime primary schools.¹²⁵ An association between poverty and child development was recorded at as early as 6 months of historic period in Egypt,¹²⁶ 12 months in Brazil,¹²⁷ 10 months in Republic of india,¹²⁸ and 18 months in Bangladesh.⁶⁸ In another Brazilian study, preschool children's linguistic communication scores were associated with maternal working only non income.¹²⁹

Longitudinal studies

Several longitudinal studies have assessed the association between wealth at birth and after educational and cognitive attainment. Socioeconomic status in infancy was associated with children's noesis at 5 years of age in Kenya.¹³⁰ In Brazil, parental income at nascence was associated with poor performance on a developmental screening test at 12 months in 1400 infants, and with school grades attained at xviii years in 2222 men on regular army enlistment.³⁸ In Guatemala,¹³¹ socioeconomic status at birth was associated with school attainment and cognition in 1469 adults. Nosotros analysed information from three other longitudinal studies (tabular array 3). Wealth quintiles at birth were related to IQ at 8 years in the Philippines,³⁶ and to cognitive scores at vii years in South Africa¹¹⁷ and 9 years in Indonesia.¹¹⁶ The effect size in all these studies was substantial, ranging from 0·70 to ane·24 SD scores betwixt the top and bottom quintiles in children from varied socioeconomic backgrounds, and from 0·45 to 0·53 SD scores in Republic of guatemala where all study children were poor. Nosotros had to use wealth quintiles rather than the cutoff of US$1 per twenty-four hours because of limitations in the data. Poor children consistently had considerable developmental deficits compared with more than affluent children. Thus poverty can be used as an indicator of poor development.

Table 3

Descriptive summary of follow-upward studies showing association between wealth quintiles in early on childhood, and later cognitive and school outcomes

	Philippines	Indonesia	South Africa	Brazil	Guatemala *
	Cerebral score (viii years of age at cess, n=2485)	Reasoning and arithmetic (9 years of historic period at assessment, n=371)	Ravens progressive matrices† 120 (vii years of age at assessment, n=1143)	Attained grades (xviii years of age at assessment, due north=2222)	Reading and vocabulary (26–41 years of historic period at assessment)
					Boys (northward=683)	Girls (n=786)
Fifth quintile (wealthiest)	56·9	12·ane	0·47	9·3	50·9	44·8
Fourth quintile	52·5 (−0·35)	11·0 (−0·31)	0·13 (−0·34)	8·2 (−0·48)
Third quintile	51·six (−0·42)	11·0 (−0·31)	−0·xvi (−0·63)	7·4 (−0·84)	43·three (−0·45)	43·6 (−0·01)
Second quintile	49·4 (−0·60)	9·5 (−0·74)	−0·20 (−0·67)	half dozen·8 (−1·11)
First quintile (poorest)	46·4 (−0·84)	8·4 (−1·06)	−0·23 (−0·70)	6·5 (−1·24)	41·0 (−0·53)	37·6 (−0·45)

Estimate of number of children who are stunted or living in poverty

We estimated the prevalence of children nether 5 years who are stunted or living in absolute poverty in developing countries. Data for the number of children in 2004 and percent living in poverty were obtained from UNICEF⁷⁵ and data for stunting obtained from WHO.⁷⁶ Of the 156 countries analysed, 126 accept a known stunting prevalence and 88 accept a known proportion living in absolute poverty (table four). We replaced missing country values of stunting and poverty with the average prevalence of the region for the purpose of estimating the proportion and number of disadvantaged children. Sensitivity assay based on imputing stunting by poverty and imputing poverty by stunting through regression analysis gave similar results to using the regional average (webappendix). The most recent poverty data we obtained was up to year 2003, with median 2000 and inter-quartile range of 4 years. The most contempo stunting data were up to twelvemonth 2004, with median 2000 and inter-quartile range of 3 years. We extrapolated all the stunting and poverty data to the year 2004 (tabular array 4).^{75,76,132,133}

Tabular array four

Prevalence and number (in millions) of disadvantaged children under 5 years by region in 2004

	Population younger than 5 years *	Per centum living in poverty * † ‡	Number living in poverty	Percentage stunted † ‡ §	Number	Percentage stunted, living in poverty or both ¶	Number stunted, living in poverty or both ¶
Sub-Saharan Africa	117·0	46%	54·iii	37%	43·7	61%	seventy·9
Middle east and north Africa	44·one	4%	1·six	21%	9·1	22%	9·9
South asia	169·iii	27%	46·3	39%	65·half-dozen	52%	88·8
Eastward Asia and Pacific	145·7	xi%	sixteen·6	17%	25·2	23%	33·half-dozen
Latin America and the Caribbean	56·5	10%	5·9	14%	7·9	19%	10·8
Key and eastern Europe	26·iv	4%	1·0	16%	4·2	xviii%	4·7
Developing countries	559·1	22%	125·half dozen	28%	155·7	39%	218·7

There are 559 million children nether 5 years in developing countries, 156 one thousand thousand of whom are stunted and 126 million are living in accented poverty (table four). To avoid the double-counting of children who are both stunted and living in poverty, we estimated the prevalence of stunting among children in poverty in countries with both indicators available, and calculated the numbers of stunted children plus the number of not-stunted children living in poverty. Nosotros refer to these children equally disadvantaged.

The relation betwixt prevalence of stunting and poverty at the land level is non-linear and can be captured by a regression line of percentage stunted=7·eight+4·two×√%poverty (using the 82 countries with available information; R²=40·ix%). Extrapolation of this regression line gives an estimate of the prevalence of stunting in people living in poverty to exist 50%. Hence, the number of children stunted or living in poverty is the sum of the total number of stunted children (156 meg) plus fifty% of children living in poverty (63 1000000) making a total of 219 one thousand thousand disadvantaged children, or 39% of all children under 5 in developing countries.

An culling estimate of the prevalence of stunting in children in poverty was obtained past assay of micro-level data from 13 Multiple Indicator Cluster Surveys¹³⁴ in developing countries with data for both stunting and a wealth alphabetize. A meta-analysis of the datasets showed that 43% of children below the poverty line were stunted. Based on this estimate, the full number of disadvantaged children is 227 million. Although the estimate of 219 million is inevitably crude, it is more than conservative than the alternative guess of 227 1000000; nosotros use the lower estimate in the rest of the paper.

Figure 4 shows the numbers of disadvantaged children in millions by region. Most disadvantaged children (89 1000000) are in southward Asia. The acme ten countries with the largest number of disadvantaged children (in millions) are: India 65, Nigeria xvi, China 15, Bangladesh 10, Ethiopia 8, Indonesia eight, Pakistan 8, Congo-kinshasa six, Uganda 5, and Tanzania iv. These ten countries account for 145 (66%) of the 219 million disadvantaged children in the developing world.

Regional distribution of the number of children under v years in millions

(A) stunted, (B) living in poverty, and (C) disadvantaged (either stunted, living in poverty, or both) in yr 2004.

Figure 5 shows the prevalence past country. Sub-Saharan Africa has the highest prevalence of disadvantaged children under v years, 61% (tabular array iv), followed past south Asia with 52%.

Pct of disadvantaged children under five years by country in yr 2004

Limitations of the estimate of numbers of disadvantaged children

More 200 one thousand thousand disadvantaged children is an exceedingly big amount. However, limitations in the data suggest that the estimate is bourgeois. We assumed that the percentage of people in absolute poverty was equal to the percentage of children in absolute poverty. This supposition probably underestimates the number of children considering poverty is associated with higher fertility levels and larger household size. Furthermore, less than United states of america$1 per twenty-four hours is an extreme measure of poverty, and children in slightly better off households are probably too at risk. Also, we did not take into account many other risk factors for poor development, such equally maternal illiteracy, unstimulating homes, and micronutrient deficiencies.

WHO recently produced new growth standards,¹³⁵ and the −2 SD curves for length and meridian-for-age are slightly college than the −2SD curves of the previous standards in certain age ranges under lx months. Therefore, if we used the new growth standards our estimate of prevalence of stunting and disadvantaged children would be slightly higher.

The precision of the judge of disadvantaged children would be improved with internationally comparable information for maternal education and stimulation in the home. We likewise need data to establish which cutoff for income and poverty is all-time for identifying children at high hazard. Internationally comparable and feasible measures of child development would produce the best gauge of disadvantaged children, and there is an urgent need to develop such measures both to more accurately assess the problem and to assess interventions.

Some of the disadvantaged children would have IQs of less than −2 SD, the level used to diagnose balmy mental retardation (IQ 50–69).¹³⁶ However, a arrears in adaptive behaviour is ordinarily needed to make the diagnosis and these information are not available, although most would have learning problems in school and restricted employment opportunities. Nosotros are concerned in this series about the loss of potential across the whole range of cerebral ability.

Economic implications of poor child evolution

Disadvantaged children in developing countries who do not reach their developmental potential are less likely to be productive adults. Two pathways reduce their productivity: fewer years of schooling, and less learning per year in schoolhouse. What is the economic cost of i less twelvemonth of schooling? Studies from 51 countries show that, on average, each year of schooling increases wages past 9·7%.¹³⁷ Although some of the studies had methodological weaknesses, this average matches another more rigorous report,¹³⁸ which reported that each twelvemonth of schooling in Indonesia increased wages by 7–11%.

Both stunting and poverty are associated with reduced years of schooling. Table 5 presents data for school grades attained in 18-year-old Brazilian men,³⁸ by income quintile at nativity and stunting status in the first ii years. We estimate from these data that the deficit attributed to being stunted (pinnacle-for-age less than −2 z scores compared with non-stunted greater than −ane z scores), stratified for income quintiles was 0·91 grades, and the deficit from living in poverty (first vs third quintile of income) stratified for stunting condition was 0·71 grades. Furthermore, the deficit from being both stunted and in poverty (first income quintile) compared with existence non-stunted and in the third income quintile was ii·xv grades.

Table 5

Attained grades in 18-year-old Brazilian men, by income level, and stunting status in early childhood^*

	Income quintile
	Poorest 20%	2nd quintile	3rd quintile	4th quintile	Wealthiest xx%
HAZ ≥ −one	six·96 (2·11)	7·10 (2·17)	vii·69 (2·05)	viii·43 (1·89)	9·twoscore (1·83)
northward	141	213	274	325	336
HAZ −i to −ii	6·67 (2·05)	half dozen·44 (2·08)	7·06 (1·92)	7·74 (1·91)	9·27 (two·03)
n	116	123	127	111	59
HAZ < −2	5·54 (two·17)	6·56 (1·98)	7·03 (two·05)	six·65 (2·42)	8·69 (2·29)
northward	71	77	38	17	13

Stunted children also learn less per year in school. Data from the Philippines has shown that, controlling for years of schooling and income, the combined reading and math examination score of stunted children was 0·72 SD beneath that of not-stunted children. This reduction was equivalent to 2·0 fewer years of schooling.⁸⁶ Regression analysis with Jamaican information³⁷ approve this finding; controlling for wealth and grade level, stunted children'due south combined math and reading test score was 0·78 SD below those of non-stunted children. Decision-making for stunting, poor children almost certainly learn less per twelvemonth in school, simply we know of no studies that assuredly estimate the deficit.

Assuming that every twelvemonth of schooling increases adult yearly income past 9%,^137,138 we estimate that the loss in adult income from beingness stunted just not in poverty is 22·2%, the loss from living in poverty but not being stunted is 5·9% and from existence both stunted and in poverty is xxx·1% (table 6). Taking into account the number of children who are stunted, living in poverty, or both (table 6), we calculate the average deficit in adult yearly income for all 219 million disadvantaged children to be 19·8%. This guess is limited by the scarcity of data for the loss of learning ability of children in poverty, and about certainly underestimates the true loss.

Table six

Deficit associated with stunting, poverty (first vs tertiary quintile of wealth), and both, in schooling and percentage loss in yearly income in developing countries

	Deficit in school grades attained	Arrears in learning power per grade in grade equivalents	Total arrears in course equivalents	Percent loss of developed yearly income per grade *	Full percentage loss † of adult yearly income (compounded)	Number (%) of children younger than 5 years in developing countries	Average percentage loss of adult yearly income per disadvantaged child
Stunted only	0·91‡	2·0	2·91	8·3%	22·2%	92·9 (16·6%)	19·8%
Poor simply	0·71§	≥0¶	0·71¶	8·3%	5·9%	62·8 (11·2%)
Stunted and poor	2·fifteen‖	≥ii·0¶	four·fifteen¶	8·iii%	xxx·1%	62·eight (11·2%)
Evidence	Brazil38	Philippines86 and Jamaica37	Sum of columns 1 and two	51 countries137 plus Indonesian study138	Combining columns 3 and 4	See table iv	Weighted average from columns 5 and 6

Clearly, disadvantaged children are destined not but to exist less educated and take poorer cerebral function than their peers but also to be less productive. In consideration of the full cost to society of poor early on child development, we demand to take into account that the next generation will be affected, sustaining existing inequities in social club with their attendant issues.⁶⁷ Where large numbers of children are affected, national development will as well be substantially affected. These costs have to exist weighed confronting those of interventions.

Conclusion

Many children in developing countries are exposed to multiple risks for poor development including poverty and poor health and nutrition. There are few national data for children'south development only our conservative judge is that more than than 200 million children under 5 years of historic period in developing countries are not developing to their full potential. Sub-Saharan African countries have the highest percentage of disadvantaged children merely the largest number alive in south Asia. The children will subsequently do poorly in school and are probable to transfer poverty to the next generation. Nosotros estimate that this loss of man potential is associated with more than a 20% deficit in adult income and will accept implications for national development. The proximal causes of poor child development are analysed in the second paper in this series.

The problem of poor child development will remain unless a substantial effort is fabricated to mount appropriate integrated programmes. There is increasing evidence that early interventions can help prevent the loss of potential in affected children and improvements can happen rapidly (run across tertiary paper in this series). In view of the high cost of poor child development, both economically and in terms of equity and individual well-being, and the availability of constructive interventions, we can no longer justify inactivity.

Search strategy and option criteria

The following databases were searched for studies in developing countries reported in English from 1985, to Feb, 2006: BIOSIS via ISI spider web of scientific discipline, PubMed, ERIC, PsychInfo, LILACS, EMBASE, SIGLE, and Cochrane Review, along with published documents from the Globe Bank, UNICEF, and UNESCO's International Agency of Education. References in retrieved papers were examined and further information sought from experts in the field. Keywords used for search 1 were: "developing countries" or "developing nations" or "third world" and "child development" or "cognitive development" or "language development" or "noesis" or "educational activity" or "school enrolment", "school dropout", "course memory", "course attained", "educational achievement". For search 2 we also used stunting or malnutrition or undernutrition, and for search 3 we used search 1 keywords and poverty or income or economical status.

Acknowledgments

UNICEF provided funding for a working grouping meeting for all of the authors with assistance from the Bernard van Leer Foundation. The UNICEF Innocenti Eye in Florence, Italian republic, hosted the meeting. Deanna Olney provided enquiry assist. Cesar Victora, Fernando Barros, Magda Damiani, Rosangela Lima, Denise Gigante, and Bernardo Horta assisted with the Brazilian data, Andres Lescano analysed Peruvian information, Shane Norris assisted with the South African information, and Tanya Abramsky analysed the Young Lives data. The sponsor of the written report had no function in report blueprint, data collection, information analysis, information interpretation, or writing of the report.

International Child Evolution Steering Group—Sally Grantham-McGregor, Patrice Engle, Maureen Blackness, Julie Meeks Gardner, Betsy Lozoff, Theodore D Wachs, Susan Walker.

Conflict of interest statement

We declare that we accept no conflict of interest.

Web Extra Fabric

Webtable:

Accomplishment in reading for sixth class students in 12 African countries

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2270351/

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