Effects of early-life poverty on health and human capital in children and adolescents: analyses of national surveys and birth cohort studies in LMICs.

The survival and nutrition of children and, to a lesser extent, adolescents have improved substantially in the past two decades. Improvements have been linked to the delivery of effective biomedical, behavioural, and environmental interventions; however, large disparities exist between and within countries. Using data from 95 national surveys in low-income and middle-income countries (LMICs), we analyse how strongly the health, nutrition, and cognitive development of children and adolescents are related to early-life poverty. Additionally, using data from six large, long-running birth cohorts in LMICs, we show how early-life poverty can have a lasting effect on health and human capital throughout the life course. We emphasise the importance of implementing multisectoral anti-poverty policies and programmes to complement specific health and nutrition interventions delivered at an individual level, particularly at a time when COVID-19 continues to disrupt economic, health, and educational gains achieved in the recent past.

Health and development from preconception to 20 years of age and human capital.

Optimal health and development from preconception to adulthood are crucial for human flourishing and the formation of human capital. The Nurturing Care Framework, as adapted to age 20 years, conceptualises the major influences during periods of development from preconception, through pregnancy, childhood, and adolescence that affect human capital. In addition to mortality in children younger than 5 years, stillbirths and deaths in 5-19-year-olds are important to consider. The global rate of mortality in individuals younger than 20 years has declined substantially since 2000, yet in 2019 an estimated 8·6 million deaths occurred between 28 weeks of gestation and 20 years of age, with more than half of deaths, including stillbirths, occurring before 28 days of age. The 1000 days from conception to 2 years of age are especially influential for human capital. The prevalence of low birthweight is high in sub-Saharan Africa and even higher in south Asia. Growth faltering, especially from birth to 2 years, occurs in most world regions, whereas overweight increases in many regions from the preprimary school period through adolescence. Analyses of cohort data show that growth trajectories in early years of life are strong determinants of nutritional outcomes in adulthood. The accrual of knowledge and skills is affected by health, nutrition, and home resources in early childhood and by educational opportunities in older children and adolescents. Linear growth in the first 2 years of life better predicts intelligence quotients in adults than increases in height in older children and adolescents. Learning-adjusted years of schooling range from about 4 years in sub-Saharan Africa to about 11 years in high-income countries. Human capital depends on children and adolescents surviving, thriving, and learning until adulthood.

Growth in Infancy and Childhood and Age at Menarche in Five Low- or Middle-Income Countries: Consortium of Health Orientated Research in Transitional Societies (COHORTS).

BACKGROUND: Earlier age at menarche is associated with behavioral and noncommunicable disease risks. The influence of birth weight (BW) (intrauterine) and postnatal growth on age at menarche is not well studied in low- and middle-income countries (LMICs). OBJECTIVE: Therefore, we investigated these associations in 5 LMIC birth cohorts. METHODS: We analyzed data from Brazil, Guatemala, India, the Philippines, and South Africa (n = 3983). We derived stunting (< -2 SD scores) at 24 mo using the WHO child growth standards. We generated interaction terms with categorized BW and conditional weight (lighter < 0 or heavier ≥ 0), and height (shorter < 0 or taller ≥ 0) z-scores. We categorized early-, modal-, and late-onset menarche and used multilevel ordinal regression. We used multilevel linear regression on continuous age at menarche. RESULTS: Mean age at menarche was 12.8 y (95% CI: 12.7 12.9). BW was not associated with age at menarche. Conditional height at 24 mo and mid-childhood (OR: 1.35; 95% CI: 1.27, 1.44 and 1.32; 1.25, 1.41, respectively) and conditional weight at 24 mo and mid-childhood (OR: 1.15; 1.08, 1.22 and 1.18; 1.11, 1.25, respectively) were associated with increased likelihood of early-onset menarche. Being heavier at birth and taller at 24 mo was associated with a 4-mo (95% CI: 0.8, 7.6) earlier age at menarche than being lighter at birth and shorter at 24 mo. Being heavier at birth but lighter in mid-childhood was associated with a 3-mo (95% CI: 0.8, 4.8) later age at menarche than being lighter at birth and mid-childhood. Age at menarche was 7 mo later in stunted than nonstunted girls. CONCLUSION: Age at menarche is inversely related to relative weight gain but also to rapid linear growth among those born shorter but remained stunted, and those born taller and grew excessively. These findings do not deter the global health goal to reduce growth faltering but emphasize the potential adverse effects of an obesogenic environment on adolescent development.

Psychological legacies of intergenerational trauma under South African apartheid: Prenatal stress predicts greater vulnerability to the psychological impacts of future stress exposure during late adolescence and early adulthood in Soweto, South Africa.

BACKGROUND: South Africa's rates of psychiatric morbidity are among the highest in sub-Saharan Africa and are foregrounded by the country's long history of political violence during apartheid. Growing evidence suggests that in utero stress exposure is a potent developmental risk factor for future mental illness risk, yet the extent to which the psychiatric effects of prenatal stress impact the next generation are unknown. We evaluate the intergenerational effects of prenatal stress experienced during apartheid on psychiatric morbidity among children at ages 17-18 and also assess the moderating effects of maternal age, social support, and past household adversity. METHODS: Participants come from Birth-to-Twenty, a longitudinal birth cohort study in Soweto-Johannesburg, South Africa's largest peri-urban township which was the epicentre of violent repression and resistance during the final years of the apartheid regime. Pregnant women were prospectively enrolled in 1990 and completed questionnaires assessing social experiences, and their children's psychiatric morbidity were assessed at ages 17-18. RESULTS: Full data were available from 304 mother-child pairs in 2007-8. Maternal prenatal stress in 1990 was not directly associated greater psychiatric morbidity during at ages 17-18. Maternal age and past household adversity moderated the intergenerational mental health effects of prenatal stress such that children born to younger mothers and late adolescent/young adult children experiencing greater household adversity exhibited worse psychiatric morbidity at ages 17-18. Social support did not buffer against the long-term psychiatric impacts of prenatal stress. CONCLUSIONS: Greater prenatal stress from apartheid predicted adverse psychiatric outcomes among children born to younger mothers and adolescents/young adults who experienced greater concurrent stress. Our findings suggest that prenatal stress may affect adolescent mental health, have stress-sensitising effects, and represent possible intergenerational effects of trauma experienced under apartheid in this sample.

Infection, nutritional status, and body composition: Associations at birth and 6 months postnatally in Soweto, South Africa.

INTRODUCTION: The impact of infection on infant nutritional status, body size, and growth is well documented. However, research into the impact of infection on infant body composition is limited. Greater understanding is, therefore, needed on the effects of infection in early life. METHODS: Associations between a composite morbidity index consisting of the sum of the cumulative tallies for a range of symptoms representing infection and morbidity in the infants and nutritional status (height-for-age (HAZ), and weight-for-height (WHZ)), and body composition (fat-free mass (FFM), fat mass (FM), fat-free mass index (FFMI), and fat mass index (FMI)) at 6 months of age were investigated using hierarchical regression analysis. RESULTS: The sample comprised data between birth and 6 months postnatally, of 156 infants who were a priori born healthy in Soweto, South Africa. Morbidity, over the cumulative period of birth to 6 months, was associated with lower FMI (ß = -1.77) and lower FM (ß = -0.61), and conversely with higher FFM (ß = 0.94), in infants at 6 months. No associations were found between the morbidity index and FFMI, HAZ, and WHZ. Increased birthweight was associated with a higher FFM (ß = 0.66), HAZ (ß = 1.14), and WHZ (ß = 0.87). Finally, safely managed sanitation facilities, representative of reduced environmental exposure to fecal-oral transmission pathways were associated with a higher HAZ (ß = 1.21). DISCUSSION: Reduction in FMI and FM and exposure to inflammatory cytokines associated with mounting an immune response could alter phenotypic trajectories during to this period of plasticity. From a public health perspective, these results imply that it is important to intensify efforts to prevent infection in infants in the first 6 months postnatally, and that these efforts should concentrate on access to safely managed sanitation facilities.

Childhood factors associated with suicidal ideation among South African youth: A 28-year longitudinal study of the Birth to Twenty Plus cohort.

BACKGROUND: Although early life factors are associated with increased suicide risk in youth, there is a dearth of research on these associations for individuals growing up in disadvantaged socioeconomic contexts, particularly in low- and middle-income countries (LMICs). We documented the association between individual, familial, and environmental factors in childhood with suicidal ideation among South African youth. METHODS AND FINDINGS: We used data from 2,020 participants in the Birth to Twenty Plus (Bt20+) study, a South African cohort following children born in Soweto, Johannesburg from birth (1990) to age 28 years (2018). Suicidal ideation was self-reported at ages 14, 17, 22, and 28 years, and the primary outcome of interest was suicidal ideation reported at any age. We assessed individual, familial, and socioeconomic characteristics at childbirth and during infancy, adverse childhood experiences (ACEs) between ages 5 and 13 years, and externalizing and internalizing problems between 5 and 10 years. We estimated odds ratios (ORs) of suicidal ideation for individuals exposed to selected childhood factors using logistic regression. Lifetime suicidal ideation was reported by 469 (23.2%) participants, with a 1.7:1 female/male ratio. Suicidal ideation rates peaked at age 17 and decreased thereafter. Socioeconomic adversity, low birth weight, higher birth order (i.e., increase in the order of birth in the family: first, second, third, fourth, or later born child), ACEs, and childhood externalizing problems were associated with suicidal ideation, differently patterned among males and females. Socioeconomic adversity (OR 1.13, CI 1.01 to 1.27, P = 0.031) was significantly associated with suicidal ideation among males only, while birth weight (OR 1.20, CI 1.02 to 1.41, P = 0.03), ACEs (OR 1.11, CI 1.01 to 1.21, P = 0.030), and higher birth order (OR 1.15, CI 1.07 to 1.243, P < 0.001) were significantly associated with suicidal ideation among females only. Externalizing problems in childhood were significantly associated with suicidal ideation among both males (OR 1.23, 1.08 to 1.40, P = 0.002) and females (OR 1.16, CI 1.03 to 1.30, P = 0.011). Main limitations of the study are the high attrition rate (62% of the original sample was included in this analysis) and the heterogeneity in the measurements of suicidal ideation. CONCLUSIONS: In this study from South Africa, we observed that early life social and environmental adversities as well as childhood externalizing problems are associated with increased risk of suicidal ideation during adolescence and early adulthood.

Impact of baby behaviour on caregiver's infant feeding decisions during the first 6 months of life: A systematic review.

Caregivers are often concerned about baby behaviours. Without adequate counselling, parental response can lead to altering infant feeding and jeopardizing breastfeeding. We conducted a systematic review to assess the evidence about the influence of baby behaviours perceived as problematic (crying, sleep waking and posseting) on infant feeding decisions during the first 6 months of life (self-reported milk insufficiency, breastfeeding duration and introduction of formula). The review focused on quantitative studies published in English, Portuguese or Spanish without date restriction. The search was designed with the support of a medical librarian and conducted in seven databases. Data were managed in Covidence and risk of bias was assessed through the Johanna Briggs Institute critical appraisal checklists. Synthesis of the literature was guided by a conceptual model of the impact of baby behaviours on caregivers feeding practices. We retrieved and reviewed 4312 titles/abstracts and selected 22 for review; 10 were purely descriptive and 12 were cross-sectional, prospective and quasi-experimental studies. Although studies from diverse regions were included in the review, more than half were from high-income countries. All studies reported that baby behaviours affect feeding decisions, the most common baby behaviours studied were crying and fussiness, and the studies suggested relationships with lactation problems and reports of milk insufficiency, maternal breastfeeding confidence, breastfeeding duration and discontinuation, and introduction of formula. There are many factors that lead to perceiving baby behaviours as problematic and there is a need to provide anticipatory guidance to parents and caregivers, starting in pregnancy and counselling through well-trained health providers.

Patterns of Growth in Childhood in Relation to Adult Schooling Attainment and Intelligence Quotient in 6 Birth Cohorts in Low- and Middle-Income Countries: Evidence from the Consortium of Health-Oriented Research in Transitioning Societies (COHORTS).

BACKGROUND: Growth faltering has been associated with poor intellectual performance. The relative strengths of associations between growth in early and in later childhood remain underexplored. OBJECTIVES: We examined the association between growth in childhood and adult human capital in 5 low- and middle-income countries (LMICs). METHODS: We analyzed data from 9503 participants in 6 prospective birth cohorts from 5 LMICs (Brazil, Guatemala, India, the Philippines, and South Africa). We used linear and quasi-Poisson regression models to assess the associations between measures of height and relative weight at 4 age intervals [birth, age ∼2 y, midchildhood (MC), adulthood] and 2 dimensions of adult human capital [schooling attainment and Intelligence Quotient (IQ)]. RESULTS: Meta-analysis of site- and sex-specific estimates showed statistically significant associations between size at birth and height at ∼2 y and the 2 outcomes (P < 0.001). Weight and length at birth and linear growth from birth to ∼2 y of age (1 z-score difference) were positively associated with schooling attainment (ß: 0.13; 95% CI: 0.08, 0.19, ß: 0.17; 95% CI: 0.07, 0.32, and ß: 0.25, 95% CI: 0.10, 0.40, respectively) and adult IQ (ß: 0.74, 95% CI: 0.35, 1.14, ß: 0.73, 95% CI: 0.35, 1.10, and ß: 1.52, 95% CI: 0.96, 2.08, respectively). Linear growth from age 2 y to MC and from MC to adulthood was not associated with higher school attainment or IQ. Change in relative weight in early childhood, MC, and adulthood was not associated with either outcome. CONCLUSIONS: Linear growth in the first 1000 d is a predictor of schooling attainment and IQ in adulthood in LMICs. Linear growth in later periods was not associated with either of these outcomes. Changes in relative weight across the life course were not associated with schooling and IQ in adulthood.

Double benefit? Integrating an early childhood development programme into HIV PMTCT Option B+ services in Malawi.

KEY MESSAGES: Benefits for mothers and children can be achieved through the successful integration of an early childhood development programme into PMTCT Option B+ services in Malawi.Our study based on in-depth interviews with 62 mothers indicated that such an approach is feasible and acceptable.Participating mothers reported that the integration of the early childhood development component improved their confidence and they believed it improved their parenting;led to improved relationships with health care providers;increased the engagement of fathers and support from others in the family;helped mothers build a new social network and support system through the peer engagement components;reduced the risk of stigmatization in the health care setting.

Initial engagement and persistence of health risk behaviors through adolescence: longitudinal findings from urban South Africa.

BACKGROUND: Little is known about longitudinal patterns of adolescent health risk behavior initial engagement and persistence in low- and middle-income countries. METHODS: Birth to Twenty Plus is a longitudinal birth cohort in Soweto-Johannesburg, South Africa. We used reports from Black African participants on cigarette smoking, alcohol, cannabis, illicit drug, and sexual activity initial engagement and adolescent pregnancy collected over 7 study visits between ages 11 and 18 y. We fit Kaplan-Meier curves to estimate behavior engagement or adolescent pregnancy, examined current behavior at age 18 y by age of first engagement, and performed a clustering analysis to identify patterns of initial engagement and their sociodemographic predictors. RESULTS: By age 13 y, cumulative incidence of smoking and alcohol engagement were each > 21%, while the cumulative incidence of other behaviors and adolescent pregnancy were < 5%. By age 18 y (15 y for cannabis), smoking, alcohol, and sexual activity engagement estimates were each > 65%, cannabis and illicit drug engagement were each > 16%; adolescent pregnancy was 31%. Rates of engagement were higher among males. Current risk behavior activity at age 18 y was generally unrelated to age of initial engagement. We identified three clusters reflecting low, moderate, and high-risk patterns of initial risk behavior engagement. One-third of males and 17% of females were assigned to the high-risk cluster. Sociodemographic factors were not associated with cluster membership. CONCLUSIONS: Among urban dwelling Black South Africans, risk behavior engagement across adolescence was common and clustered into distinct patterns of initial engagement which were unrelated to the sociodemographic factors assessed. Patterns of initial risk behavior engagement may inform the timing of primary and secondary public health interventions and support integrated prevention efforts that consider multiple behaviors simultaneously.

Father involvement, maternal depression and child nutritional outcomes in Soweto, South Africa.

Father involvement in South Africa is low, despite evidence that it can improve maternal and child health and wellbeing. Within a larger randomised controlled trial, we assessed whether father involvement during and after pregnancy increased birth weight and exclusive breastfeeding through improved maternal mental health. At 6-week postnatal, mothers completed questionnaires on birth, feeding practices, social support, father involvement and postnatal depression. Father involvement during pregnancy was measured by their attendance at antenatal care and the study intervention, whereas postnatal involvement was measured by attendance at antenatal care and type of paternal support provided. Structural equation modelling was used to identify associations between father involvement, maternal depression, low birth weight and exclusive breastfeeding. Among the 212 mother-baby pairs, father involvement was very low with only 43%, 33% and 1% of partners attending early ultrasound, antenatal care and the birth of the child, respectively. Twenty-nine percent of the mothers showed signs of depression during pregnancy, compared with 7% after birth. Eighteen percent of the infants were born low birth weight, and 57% of mothers reported exclusively breastfeeding at 6 weeks. Father involvement was directly associated with postnatal depression, but it did not directly or indirectly impact exclusive breastfeeding or low birth weight. We conclude that postnatal father involvement can improve postnatal maternal depression and that men would benefit from specific guidance on how they can support mothers during and after pregnancy.

Gender norms and health: insights from global survey data.

Despite global commitments to achieving gender equality and improving health and wellbeing for all, quantitative data and methods to precisely estimate the effect of gender norms on health inequities are underdeveloped. Nonetheless, existing global, national, and subnational data provide some key opportunities for testing associations between gender norms and health. Using innovative approaches to analysing proxies for gender norms, we generated evidence that gender norms impact the health of women and men across life stages, health sectors, and world regions. Six case studies showed that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programmes. Limitations of survey-based data are described that resulted in missed opportunities for investigating certain populations and domains. Recommendations for optimising and advancing research on the health impacts of gender norms are made.

Investing in the foundation of sustainable development: pathways to scale up for early childhood development.

Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.

Stunting at 24 Months Is Not Related to Incidence of Overweight through Young Adulthood in an Urban South African Birth Cohort.

Background: The role that childhood stunting plays in the development of overweight and obesity later in life is not well understood, particularly in adolescence and young adulthood, because most studies have only followed up through midchildhood. Objective: The objective of this study was to examine the relation between stunting and age-specific patterns of overweight and obesity incidence from early childhood to young adulthood in the context of a country in the process of the nutrition transition while these children were growing up. Methods: We analyzed data from 895 participants in the Birth-to-Twenty Plus Cohort (Bt20+), an urban South African birth cohort initiated in 1990. Anthropometric data were collected at multiple ages and participants were included if they provided height at age 24 mo and ≥1 measure of body mass index [BMI; weight (kg)/height (m)2] in each of the following time periods: 4-8 y, 11-12 y, 13-15 y, 16-18 y, and 22-24 y. We defined stunting at age 24 mo as height-for-age z score <2 and overweight as BMI z score (BMIZ) >1 in childhood (4-8 y) and adolescence (11-12 y, 13-15 y, and 16-18 y) and BMI ≥25 in young adulthood (22-24 y). We compared BMI, BMIZ, and the prevalence of overweight by stunting status, stratified by sex. Results: Our sample was 93% black and 51% female. The prevalence of stunting at 24 mo was 26% in males and 19% in females. In young adulthood, the prevalence of overweight and obesity was 15.5% (men) and 47.5% (women). Among both males and females, neither mean BMI nor a combined measure of overweight and obesity in any subsequent period differed by stunting status at 24 mo (P ≥ 0.05). Conclusion: Stunting at 24 mo was not related to the risk of overweight or obesity in this cohort. Stunting may not be an important contributor to the increasing obesity rates in urban South Africa.

Comparative Models of Biological and Social Pathways to Predict Child Growth through Age 2 Years from Birth Cohorts in Brazil, India, the Philippines, and South Africa.

Background: Early growth faltering accounts for one-third of child deaths, and adversely impacts the health and human capital of surviving children. Social as well as biological factors contribute to growth faltering, but their relative strength and interrelations in different contexts have not been fully described. Objective: The aim of this study was to use structural equation modelling to explore social and biological multidetermination of child height at age 2 y in longitudinal data from 4 birth cohort studies in low- and middle-income countries. Methods: We analyzed data from 13,824 participants in birth cohort studies in Brazil, India, the Philippines, and South Africa. We used exploratory structural equation models, with height-for-age at 24 mo as the outcome to derive factors, and path analysis to estimate relations among a wide set of social and biological variables common to the 4 sites. Results: The prevalence of stunting at 24 mo ranged from 14.0% in Brazil to 67.7% in the Philippines. Maternal height and birthweight were strongly predictive of height-for-age at 24 mo in all 4 sites (all P values <0.001). Three social-environmental factors, which we characterized as "child circumstances," "family socioeconomic status," and "community facilities," were identified in all sites. Each social-environmental factor was also strongly predictive of height-for-age at 24 mo (all P values <0.001), with some relations partly mediated through birthweight. The biological pathways accounted for 59% of the total explained variance and the social-environmental pathways accounted for 41%. The resulting path coefficients were broadly similar across the 4 sites. Conclusions: Early child growth faltering is determined by both biological and social factors. Maternal height, itself a marker of intergenerational deprivation, strongly influences child height at 2 y, including indirect effects through birthweight and social factors. However, concurrent social factors, many of which are modifiable, directly and indirectly contribute to child growth. This study highlights opportunities for interventions that address both biological and social determinants over the long and short term.

Stress begets stress: the association of adverse childhood experiences with psychological distress in the presence of adult life stress.

BACKGROUND: Adverse childhood experiences (ACES) have been linked to poor health and well-being outcomes, including poor mental health such as psychological distress. Both ACEs and psychological distress pose a significant public health burden, particularly in low to middle income countries. Contemporaneous stress events in adulthood may also impact psychological distress. The aims of this study were to describe the prevalence of ACEs and psychological distress and to assess the separate and cumulative effect of ACEs on psychological distress, while accounting for the effect of adult stress. METHODS: In this cross-sectional study, we used retrospectively measured ACEs from a sample of 1223 young adults aged between 22 and 23 years (52% female) from the Birth to Twenty Plus Study. Psychological distress and adult life stress were measured with a six-month recall period. Hierarchical logistic regression was employed to assess the associations between the exposures and outcome. RESULTS: Nearly 90% of the sample reported at least one ACE and 28% reported psychological distress. The median number of ACEs reported was three (range 0-11). After accounting for demographic and socio-economic factors, all ACEs were individually associated with psychological distress except for parental divorce and unemployment. The individual ACEs increased the odds of PD by between 1.42 and 2.79 times. Compared to participants experiencing no ACEs, those experiencing one to five ACEs were three times more likely to report psychological distress (AOR 3.2 95% CI: 1.83-5.63), while participants who experienced six or more ACEs had nearly eight times greater odds of reporting psychological distress (AOR 7.98 95% CI: 4.28-14.91). Interaction analysis showed that in the absence of adult life stress, the effect of low ACEs compared to high ACEs on PD was not significantly different. DISCUSSION AND CONCLUSION: The prevalence of ACEs in this young adult population is high, similar to other studies in young adult populations. A significant direct association exists between ACEs and psychological distress. Adult life stress seems to be a mediator of this relationship. Interventions targeted at psychological distress should address both early life adversity and contemporary stress.

Nurturing Care for Young Children under Conditions of Fragility and Conflict.

Forced displacement worldwide is at its highest in decades and millions of young children are living in conflict zones, in transitional or enduring refugee contexts, and in demographically diverse marginalized and informal settlements. There is a huge unmet need for delivering early childhood development interventions to ensure the safety and continued development of young children in these vulnerable contexts. In this paper, we discuss nurturing care as an important entry point for multisectoral collaborations to support families and reach young children. Nurturing care is a basic right of every child and encompasses health, nutrition, security and safety, responsive caregiving, and early learning. We review key elements of the biological and psychological development of children important to nurturing care and illustrate their application in case studies of war and displacement in Angola and Kenya. Building on long-term benefits of early interventions, scaled up support is essential to improve the health, development, and well-being of young children in contexts of conflict, violence, and insecurity. Not only do early childhood development interventions support the development of young children, but they also provide a potential pathway to violence reduction and a way to achieve more peaceful families, communities, and societies.

Why invest, and what it will take to improve breastfeeding practices?

Despite its established benefits, breastfeeding is no longer a norm in many communities. Multifactorial determinants of breastfeeding need supportive measures at many levels, from legal and policy directives to social attitudes and values, women's work and employment conditions, and health-care services to enable women to breastfeed. When relevant interventions are delivered adequately, breastfeeding practices are responsive and can improve rapidly. The best outcomes are achieved when interventions are implemented concurrently through several channels. The marketing of breastmilk substitutes negatively affects breastfeeding: global sales in 2014 of US$44·8 billion show the industry's large, competitive claim on infant feeding. Not breastfeeding is associated with lower intelligence and economic losses of about $302 billion annually or 0·49% of world gross national income. Breastfeeding provides short-term and long-term health and economic and environmental advantages to children, women, and society. To realise these gains, political support and financial investment are needed to protect, promote, and support breastfeeding.