This document discusses integrated programming to promote child development through improving water, sanitation, hygiene (WASH), nutrition, and early childhood development (ECD). It notes that undernutrition and diarrhea often occur together, negatively impacting nutrient absorption. Improving WASH behaviors like handwashing can significantly reduce diarrhea prevalence. Environmental enteropathy, caused by too many gut microbes and toxins, also impairs nutrient absorption. The period from 6 months to 3 years sees the most rapid growth faltering. Integrating nutrition and ECD interventions has strong synergistic effects on child development outcomes. While integration offers advantages like efficiency, it also presents challenges around coordination, measurement, and staff workload that need addressing.

1. Nora Zenczak-Skerrett, Early Childhood Development Technical Coordinator, ChildFund
International
Lenette Golding,, FHI 360, Alive and Thrive, Program Director, Nigeria
Renuka Bery, FHI 360, Senior Program Manager, WASHplus
Sr. Pauline Acayo, Catholic Relief Services
CORE Group Spring Meeting
May 2016
Integrated Child Development:
The Whole Child Perspective
A brief introduction to holistic, global WASH, nutrition, and ECD
programming to improve child development outcomes for children 0-3

2. What is Clean, Fed & NurturedSM?
• Community of Practice focused on
Integrated programming
 Water, sanitation, hygiene (WASH)
 Nutrition
 Early childhood development (ECD)
• Goal
 To promote thriving children

3. Objectives of today’s session
• Review what we know
• Examine groundbreaking research for
integration
• Map the global integrated ECD portfolio
• Commit to strengthen integrated
approaches to improve outcomes for
infants and young children

4. Building the Case
for Integration:
The 3 Legged Stool

5. Undernutrition
Diarrhea
What do we know about
WASH + nutrition?
• Children with diarrhea tend to eat less
• With diarrhea, nutrients from food are not well-absorbed
• Undernourished children are more susceptible to diarrhea

6. Safe Storage & Treatment of Water
Handwashing
Safe Feces Disposal
Focus on WASH behaviors for
Diarrhea Disease Reduction….
30% ++
43%
30-50%
Review of the
evidence

7. 0%
5%
10%
15%
20%
25%
10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
Meandiarrheaprevalence
None
Month
2007 2008 2009
Prevalence of diarrhea among children < 5 years
by observed handwashing before preparing food
SHEWA-B, Rural Bangladesh
12.5%
PLoS Med, 2011;8(6): e1001052.

8. 0%
5%
10%
15%
20%
25%
10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
Meandiarrheaprevalence
None
Water
Water + Soap
Month
2007 2008 2009
12.5%
8.3%
PLoS Med, 2011;8(6): e1001052.
Prevalence of diarrhea among children < 5 years
by observed handwashing before preparing food
SHEWA-B, Rural Bangladesh

9. 0%
5%
10%
15%
20%
25%
10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
Meandiarrheaprevalence
None
Water
Water + Soap
Month
2007 2008 2009
12.5%
8.3%
6.9%
PLoS Med, 2011;8(6): e1001052.
Prevalence of diarrhea among children < 5 years
by observed handwashing before preparing food
SHEWA-B, Rural Bangladesh

10. • A subclinical condition of the
small intestine, called
environmental enteropathy (EE)
• Characterized by:
– Flattening of the villi of the gut, reducing its surface area
– Thickening of the surface through which nutrients must be
absorbed
– Increased permeability to large molecules and cells (microbes)
• Likely causes:
– Too many microbes in the gut
– Effects of toxins on the gut
The Environmental
Enteropathy Hypothesis
Slide from Cornell U Division of Nutritional Sciences, Laura Smith . R Stoltzfus, F Ngure, B Reid, G Pelto, M Mbuya, A Prendergast, J Humphrey

11. -2.5
-2
-1.5
-1
-0.5
0
0.5
1 3 5 7 9 11 13 15 17 19 21 23 25
Length-for-ageZ-score
Age (mo)
Boys WHO Girls WHO
Boys NCHS Girls NCHS
KK Saha et al (ICDDR,B),
Food and Nutrition Bulletin 2009
Most rapid decline during 3-15 months
<< “Normal
Most stunting damage
occurs during complementary feeding age

12. Sanitation alone explains 54% of
international variation in child
height - GDP only explains 29%
Source: Each data point is a collapsed DHS survey round (country-year), proportional to population. Spears (2012)
www.riceinstitute.org #13
Open defecation accounts for
much of excess stunting

13. Stunting has lifelong implications…
A stunted child will never learn or earn
as much as if they’d been properly nourished…
And the damage can’t be un-done…

14. What do we know about integrating
nutrition + ECD?
• The impacts of ECD interventions on child
development outcomes are very significant and
well documented.
• The evidence of the importance of integration
between ECD and nutrition is growing rapidly.

15. 219 million children (39%) < age 5
in low and middle income
countries do not reach their
developmental potential
The Challenge

16. Fetus Late Infancy/Toddler Pubertal
Developmental Perspective
Thompson & Nelson, 2000
Iron: 0.27 mg/day 11 mg/day 7 mg/day
0–6 months 6-12 months 1-3 years
1000 days
Slides taken from Maureen Black’s 2016 CIES Presentation

17. Integrated Interventions are Stronger
Slides taken from Maureen Black’s 2016 CIES Presentation

18. Early Childhood Development:
Multiple Contributing Factors
Slides taken from Maureen Black’s 2016 CIES Presentation
.
Socio-
cultural
Poverty
Caregiving
Nutrition
Brain
Development &
Functioning
Motor
Social
Emotional
Growth
Cognitive
Language
WASH

19. Source: Walker SP, Wachs TD, Grantham-McGregor S, Black MM , Nelson CA, Huffman SL, Baker-Henningham H, Chang
SM ,Hamadani JD, Lozoff B, Meeks-Gardner JM, Powell CA, Rahman A, Richter L. Inequality in early childhood: risk and
protective factors for early child development. The Lancet, Early Online Publication, 23 September 2011.
Protective Factors get children back on
track to reach their potential

20. Advantages of integration
• Advantages:
– Hypothetical synergies for improved growth and
development
– Efficiency through use of same facilities,
personnel
– Increased access to services for most
disadvantaged
– Seamless approach is the way families raise a
child
Adapted from: DiGirolamo, A. M., Stansbery, P. and Lung'aho, M. (2014), Advantages and challenges
of integration: opportunities for integrating early childhood development and nutrition programming.
Annals of the New York Academy of Sciences, 1308: 46–53. doi: 10.1111/nyas.12323

21. Challenges of integration
• Staff motivation, workload
• Coordination among agencies,
organizations
• Lack of common language and
measurement indicators
• Funding by silo
• Growing evidence base but not in all areas
• Overload for families
Adapted from: DiGirolamo, A. M., Stansbery, P. and Lung'aho, M. (2014), Advantages and challenges of integration:
opportunities for integrating early childhood development and nutrition programming. Annals of the New York
Academy of Sciences, 1308: 46–53. doi: 10.1111/nyas.12323