THE FIRST 1000 DAYS

• J

Dr. Antonius SpA

1st 1000 days to City of Cape Town Health 2
 The First 1000 Days “continuum”

• 270 + 365 + 365 = 1000 

1000 Days

Early postnatal /
Antenatal Early Childhood
Infancy

-9 -6 -3 0 3 6 9 12 15 18 21 24

Conception Birth

Acknowledgement: Linda Aldair

Development of the brain – which is linked to:
The First 1000 Days: New Neuroscience
1. Nutrition in the first 1000 days
2. The mother’s mental well being
3. Parenting: Quality of relationships / attachment
4. Stimulation in a safe and protected environment
5. The four building blocks and impact of early childhood
development
6. The problem of toxic stress
7. Vulnerability of babies and infants
1st 1000 days to City of Cape Town Health 4
 Nutrition in the first 1000 Days

• Optimal development of the brain requires

optimal nutrition from conception

• However

More than food is needed

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 Nutrition in the first 1000 Days

• Stress and Nutrition interact with each

other in the First 1000 Days affecting
how the brain and body absorb
nutrients and influencing the child’s
development – both cognitive and
physical
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 New Neuroscience: The
significance of the mother’s mental well being
• A fetus or baby exposed to toxic stress can  distorted
stress response in later life

• This early stress can come from the mother suffering

from:
o depression or anxiety
o bad relationship with partner or exposure to violence
and abuse
o an external trauma such a bereavement
o food insecurity
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Parenting: Quality of Relationships/‘Attachment’

• The baby’s social, emotional and

cognitive development is affected by
the quality of attachment to the
caregiver /s.

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Parenting: Quality of Relationships/’Attachment’

Babies who have warm, loving and responsive care in the

first few months of their lives, develop empathy, are able
to deal with the emotional and social stresses of life, and
have the emotional and mental tools to have good
relationships with others.

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 New Neuroscience:
Stimulation in a safe and protective environment

Infants and babies who are spoken with, played with, and
helped to experience the world in a kind and loving way have
the mental, social and emotional tools to cope well at school
later

It starts with the mother, parents / caregivers  but early

childhood learning and development (Educare) is also vital

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Prenatal stress reduces an enzyme which metabolizes cortisol
The Problem of Toxic Stress
High level of cortisol in the amniotic fluid

Has a negative effect on infant cognitive development

• Toxic stress is defined as the excessive or prolonged activation of the

physiologic stress response without the buffering protection
afforded by stable, responsive relationships

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 The Problem of Toxic Stress

A toxic intra-uterine
1st 1000 days to City of Cape Town Health 12
environment causes
pre-natal stress
 The Problem of Toxic Stress

The earliest experiences shape a baby’s brain development

and have a lifelong impact on the baby’s mental and
emotional health

Plasticity

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Adaptive Maladaptive
 New Neuroscience:
Vulnerability of babies and infants

• If things go wrong…

• Babies and infants are more vulnerable to abuse and neglect

than older children

• Abused or neglected children, who don’t have a healthy bond

with a caring adult, are at risk of not coping at school,
becoming the victim or perpetrator of violence and are likely to
struggle later in life

1st 1000 days to City of Cape Town Health 14

• A fetus or baby
exposed to toxic
Vulnerability
stress can have their
of babies and infants
responses to stress
distorted in later
life.

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• For vulnerable and disadvantaged children =SERIOUS!
And so the Implications are….
• Inequity begins during pregnancy and is well established in the first
few days and weeks of life

• HCW’s need to focused on this crucial time to close the gap that
prevents children from their right to develop fully and thrive.

• Intersectoral action is critical to optimize brain development, overall

health and well being.

1st 1000 days to City of Cape Town Health 16

• Many things we need can wait. The child cannot. Now is the time
Inhisconclusion…..
his bones are formed, mind developed. To him we cannot say
tomorrow, his name is today.
• Gabriela Mistral

17
 • )

1st 1000 days to City of Cape Town Health 18

1st 1000 days to City of Cape Town Health 19
Nutrition in the first 1000
DAYS of life

(Paediatrician)
• To highlight the importance of nutrition (Nutr) in early brain &
child development
Objectives
• To discuss proven, low-cost nutr solutions that can make the
difference between life & death especially (esp) in developing
countries
• Emphasize on breastfeeding code, codex alimentarius & safety
• To open up on some existing legislations
 Agenda

It’s all about nurturing relationships. Early nutr

build their brains and our future.
Change the First two to five Years of a child and You
Change Everything

http://www.youtube.com/watch?v=GbSp88PBe9E
 The concept of 1000 days
• Stunting usually occurs during fetal life, from birth up to 2
years of life

• Stunting is a global phenomenon

• The 1st 1000 days of life = 270 days (9 months of pregnancy)

+ 365 days (1st year of life) + 365 days (2nd year of life).
 Take home message
• 4 types of malnutr: stunting, wasting underweight &
micronutrient deficiency
• 6 life saving solutions: Zinc, Vit A, Iron, Breastfeeding
(BF), Complimentary feeds (CF), & good hygiene. These
interventions can ↑se family earnings by 46%, GDP by 2-
3%.
• Iron & folate supplements (supl) for pregnant women cost just
$2 per pregnancy
• 1/5th of maternal deaths & stunting could be prevented by
interventions above
The architecture of the brain depends on the
mutual influences of the following

• Genetics
• Environment
• Experience driver is nutr
What shapes the developing brain?
 > 70% of adult weight

Synapses form based

Born with lifetime on early experiences
supply of neurons

Newborn Brain
Average Weight 2 Year Old’s Brain
333 grams Average Weight
999 grams
Facts

• Over 170 million under 5 are stunted as a result of

malnutr world-wide

• 52 million are too thin and require special treatment

& 2.6 million die yearly

• 2 billion people are deficient in key micro nutrients

• Alarming no of children are not getting adequate

nutrition during their first 1,000 days
• Out of 73 developing countries which together account for 95 %
of child deaths, only 4 score very good on young child nutr
(Malawi, Madagascar, Peru & Solomon Islands)
• More than 2/3rd of the countries received grades of fair or poor
• Bottom 4 countries were Somalia, Côte d'Ivoire, Botswana &
Equatorial Guinea
• Put to the breast within 1 hour of birth =38%
Nigeria ranked 38 out of 73
• Exclusively BF (first 6 months) = 13%
• BF with CF (6-9 months) = 75%
• BF at age 2 = 6%
• In Belgium and the UK, only ≈ 1% of children are exclusively
breastfed.
• Poor compliance with BF costs the world economy billions of
dollars each year
• US alone, low rates BF add $13 billion to medical costs
• UK, National Health Service spent £35 million treating diarrhoea
in formula-fed babies
• For every 1% ↑se in BF, £500,000 would be saved
• Stunting, is on the rise in sub-Saharan Africa
• If the trend continues, Africa may overtake Asia as the region
heavily burdened by child under-nutr
• Well nourished children are more productive than those who
were malnourished
• Nutr interventions can ↑se adult earnings by as much as 46%
• Malnutr costs many developing nations 2-3% of GDP yearly
• Globally, the direct cost of child malnutr is estimated at $20 to
$30 billion per year
• Breakdown
• Iron, vitamin A and zinc cost about $1 to $2 per person, per year
• BF, CF and good hygiene delivered through community nutr
programs cost $15 per household or $7.50 per child
• To little attention is being given to campaign on CF compared to
BF practices
• Cronobacter (E-Sakazakii)
Why should we invest in nutr in the 1st 1000days
Because when..
Children
Girls & women are Children receive
receive proper
well-nourished and proper nutrition and
have healthy
nutrition and
develop strong
newborn babies develop
bodies &strong
minds
bodies &
minds

The world is a Adolescents learn

Communities & safer, more better & achieve
nations are resilient & higher grades
productive & stable stronger place in school

Families & Young adults are

communities emerge better able
out of poverty to obtain
work & earn more
A smart investment

• Nutr investments can help

break the cycle of poverty
and increase a country’s
GDP by at least
2 to 3% annually.

• Investing $1 in nutr can

result in a $30 return in
increased health, schooling
and economic productivity.
Experts agree
The Copenhagen Consensus. Expert
Panel of world renowned
economists identified the smartest
ways to allocate money to respond
to ten of the world’s biggest
challenges.
They agreed that fighting
malnutr should be the top
priority for policy-makers &
philanthropists.
One of the most
compelling investments is
to get nutrients to the
world’s undernourished.
The benefits from doing
so in terms of increased
health,
“ schooling, and
productivity – are
tremendous,”
-Nobel laureate
economist Vernon Smith
 Benefits to a child
• Lesser risks of illness, obesity, allergies & sudden infant death
syndrome (SIDS)
• Less doctor visits, hospitalizations & prescriptions
• Enhancement of a child’s cognitive development
• Provides the most complete form of nutrition for infants
 Benefits to a mother/environs
• Lower risks of breast & ovarian cancers
• Delays return to fertility and helps a mother achieve pre-
pregnancy weight
• Reduces the risk of type 2 diabetes
• Increases physical & emotional bond between a mother and her
child
• Cheap
• BF is environment friendly. It does not require packaging,
storage, transportation or refrigeration
• It generates no waste, is a renewable resource & requires no
energy to produce (except of course, the calories burned by the
mother’s body)
• Few exceptions when BF is not advised, i.e mother on certain
drugs or infected with HIV or TB (AFASS)
Stunting: A silent emergency!
• Nigeria has 41% ofImplication
her under fives stunted
(FMOH,2014). It ranks 2nd after India
• According to WHO, the severity of the situation is very
high when stunting is above 40%
• It requires immediate action
• Women of short stature creates an inter-generational
cycle of stunting
 What is stunting?
• Stunting is being short for one’s age if compared to the reference
population (healthy and well nourished children of the same age)

Normal height/age Low height/age

Musa, 5 years okonkwo, 5 years

old old, stunted
 Effect of Stunting syndrome
• Developmental delay (milestones)
• Impaired immune function (↑se morbidity & mortality)
• ↓sed cognitive function (thought, learning etc.)
• ↑se risk of non communicable dxs in adulthood e.g. obesity,
HBP, Alzheimer's, Diabetes etc. (Thrift hypothesis & our
study)
• Juvenile tropical pancreatitis syndrome
 Is stunting syndrome reversible?
• Stunted children experience little or no catch-up growth later in
life
• Mental and cognitive impairment are often permanent and
irreversible after the age of 24 months
• Pinstrup-Anderson "triple burden of malnutr," hunger (dietary
deficiency), micronutrient deficiencies & obesity co-existing
Causes of malnutr are interconnected

Lack of good
Insufficient access to Inadequate access
affordable, nutritious CARE to

FOOD for mothers & children

& support for mothers
on appropriate child
HEALTH
sanitation & clean
throughout the year
feeding practices water services

ROOTED
Political & IN Disempowerme
Poverty
Cultural nt of women
Environment
ANTENATAL SAFE BIRTH &
VACCINATIO DEWORMING
CARE NORMAL BIRTH
NS
WEIGHT BABY
VITAMIN A

1 ,0 0 0 C RITICAL DAYS
EXTRA MEAL/ DIVERSE GROWTH MONITORING & PROMOTION
DIET
IRON & FOLIC ACID
EXCLUSIVE CONTINUED
BREASTFEEDING BREASTFEEDING
CORRECT COMPLEMENTARY FEEDING & FOODS
PMTCT (NUTRITION AND BREASTFEEDING
OPTIONS)
FORTIFIED STAPLES
CORRECT FEEDING OF A SICK
CHILD
USE IODIZED SALT
SLEEP UNDER TREATED BED
NETS SAFE WATER & CAREFUL
• BF: Human milk supply all nutrients & prevent diseases
(probiotic & prebiotic i.e galacto & fructo-
oligosaccharide). Contains non volatile FA (stearin, olein &
palmitin) digestion
• Animal milk is not digestible (allergy) due to ↑volatile FA i.e.
butyric, capric acids, caprylic & caproic it also has high
solutes (minerals). It should be avoided
• Exclusive BF prevents contamination of feeds from water used
in mixing infant formula
• Babies are at least 6 times more likely to survive with BF (BFHI)
• CF: @ 6mo breast milk is insufficient, other foods and liquids
must be added plus breast milk (cereal/legume mix per 100g
serving)
• If child is breastfed, give CF 3 times daily if not on BF, give CF 5
times daily
• Optimal CF involves factors such as quantity & quality of food,
frequency, timeliness, food hygiene (FADUSS)
• By 12 mo, CF becomes the main source of energy
• Spoon or a cup be used, not feeding bottle. Adequate serving
means the child doesn’t want any more food after active feeding
& some food is left on the plate
• Ample time must be given for the child to learn to eat solid foods
• Rates of malnutr peaks during this time because low density
food replaces breast milk
• Diarrhoeal illnesses equally high due to food contamination at its
peak
• BF, CF & Marketing legislation
• No promotion of breast-milk substitutes, bottles & teats to the
general public
• Neither health facilities nor health workers should have a role in
promoting breast-milk substitutes
• Free samples shouldn’t be given to pregnant women, mothers or
families
• National legislation is needed to enforce this code
• National laws that are properly enforced can stop baby food
companies from competing with BF & to ensure safety aswell
(NAFDAC, FAO, WHO, HACCP)
• Codex alimentarius (composition of formula)
• Only 1/3rd of the 96 countries who had enacted the Code
legislation had effective monitoring mechanisms in place
• Vit A supl: 1/3RD of all under 5 (190 million) and 15% of
pregnant women (19 million) do not have enough vit A in their
daily diet
• Vit A def contributes to 1.3 million deaths yearly from diarrhea
& nearly 118,000 deaths from measles
• Severe deficiency can also cause corneal damage & blindness
• Vit A given to children 2x a year can prevent blindness and lower
a child’s risk of death from common diseases by 2%
• Vit A can also be given to a child at 6monthly interval from 6mo
of age to 5yrs
• Zinc & ORS for diarrhea: makes recovery more quickly, lessen
reocurrences, ↓ses mortality by 4%
• Water, sanitation and hygiene: Hand washing with soap is an
effective & inexpensive way of preventing diarrhoea &
pneumonia
• Which together are responsible for ≈ 2.9 million child deaths
yearly
• 3% of child death could be prevented with access to safe
drinking water, good sanitation and hygiene practices
 Tackling malnutrition requires a multi-sectoral
approach!
The multi-
stakeholder
Social Protection via political &
platform sociocultural participation, human
rights, CSO, FBO
SDG 8
Health policies
SDG 4-6
SHP

Agricultural
Women’s empowerment policies
via SME’S, SMEDAN, SDG 1 & 7
NDE, NAPEP, YOU WIN,
Skills acquisition centres
SDG 3

Development &
Education policies Poverty Reduction
SDG 2 SDG 1
 Global actors

Country
Network

Civil Society United Nations

Network Network

Donor Business
Network Network
 Examples of interventions
Direct Nutrition Interventions
Ntrition sensitive Interventions
 Promote BF/CF
 Vit A, zinc, Fe suppl etc
 Micronutrients fortification
 Rx of malnutrition
[micronutrient powders,
Deworming, Salt iodization,
ready-to-use therapeutic
foods (RUTF)]
 Food security and
agriculture: maternal
dietary suppl
 Water, sanitation and
hygiene promotion
 Health: adolescent health
and preconception nutrition
 Education: 2 extra meals
for both pregnant women &
children)
Equity for women

At the core of all efforts,

women should be empowered
to be leaders in their families and
communities, leading the way to a
healthier and stronger world.
Why women empowerment?
• Women comprise ≈1/2 of the agricultural workforce in Africa
• They often bring home water, food & prepare family meals
• They are the primary family caregivers & often eat last & least
• Given any resources, they often spend them on the health and
well-being of their families
• Their own health & practices determine the health & prospects
of the next generation

• Sadly, even in the US, the environs is not too friendly for BF
mothers based on maternity leave laws & right to nursing breaks
at work

• Norway tops the BF Policy

 Challenges to nutr in 1st 1000days
Dearth of health personnel
• esp those on front lines community health workers (CHW) 3mil
gap
• Global health workforce ≈ 59 mil
• Africa = 1, 640, 000
• 1 CHW to 500-1000 population
• Clinicians: Cameroon 1:5,300, chad 1:25,000, Malawi 1:50,000,
India 1:1700 populations
• EU standard 2-4/1000 population
• Worldwide average 1:1500 (HSCIC, 2O13)
• Cuba best in the world 1:170, spend ≥ 10% budget on health
Cultural beliefs, lack of knowledge & misinformation
• Many women & families are unaware of the benefits of exclusive
BF
• New mothers may be told to wait several hours or days before
BF
• Intense marketing of infant formula often gives the impression
that it is better than human milk
• Mothers may be told their breast milk is bad or does not contain
sufficient nutrients
Race, ethnicity, education & income levels
• Whites > Hispanics/Latinos>Blacks
• Geographical area : Aboriginal mothers less likely to breastfeed
than non-Aboriginal mothers elsewhere
• ↑se BF found among mothers from managerial & professional
occupations, those with highest education levels and those age 30
and older
• Racial difference is more superior than all
• Most BF problems occur in the first 2 weeks of a child’s life
• If a mother experiences pain or the baby does not latch, an
inexperienced mother may give up
• Support from family, peer groups & health workers can help a
mother gain confidence, overcome obstacles & prolong BF
• Women often stop BF because of work. Many aren’t provided
with paid maternity leave, nursing break time & a private place
for BF
 Recommendations
• Invest in low cost solutions to save children’s lives and prevent
stunting
• Give 200,000 IU Vitamin A to a mother 6-24hrs, 3 & 7days &
6weeks after birth
• Counsel a lactating mother to take at least 2 more meals than
usual
• Six months of exclusive BF
• Timely and appropriate CF
• Invest in health workers esp CHW
• Girl child education: formal & non-formal training give girls
knowledge, self-confidence, practical skills & hope for a bright
future
• ↑se government support for solutions to fight malnutrition e.g.
immunization, social, political and economic empowerment
programs
• Countries should endorse and support the Scaling Up Nutrition
(SUN)
• ↑se private sector partnerships esp in fortification of food with
micronutrients
• Compliance with codes & standards, on good feeding practices
• Food industry to invest more in nutr programs and research
• Improve laws, policies & actions that support families and
encourage BF
• Such policies would give families access to fully paid maternal,
paternal leave and equally paid nursing break time
• Longer periods of paid maternity leave and a paid nursing
break time for an hour or more when a mother returns to
work improves exclusive BF, Denmark, Norway & Sweden
are good examples

• Depending on the country, maternity leave can range from

12 to 46 weeks, with pay from 55 to 100 percent of regular
salary
• Ensure that workplaces and public facilities offer mothers a
suitable place to feed their babies outside of the home (Crèche)
• Ensure working women are guaranteed BF breaks while on the
job
• In urban world, public transportation can offer special seats for
BF mothers
 Nutr scale-up

Together, countries and supporting stakeholders are

collectively working to reach the global targets set out by
the World Health Assembly
• Target 1:40% ↓number of children under 5 who are stunted
• Target 2: 50% ↓ anemia in women of reproductive age
• Target 3: 30% ↓ low birth weight
• Target 4: ↑ EBF up to at least 50%
• Target 5: ↓ childhood overweight
• Target 6: ↓ childhood wasting to < 5%
Successes achieved in reducing stunting
AAR Data
Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Latest
R Source
SMART
Mauritania 39.5 28.9 23.0 18.0 18.0 7.5%
2011
Ghana 35.6 28.1 28.0 28.0 4.9% DHS 2008
El FESAL
24.6 19.2 19.2 4.8%
Salvador 2008
Mali 42.7 38.5 27.8 27.8 4.6% DHS 2006
Peru 31.3 29.8 28.0 24.0 19.5 19.5 3.9% DHS 2011
Nepal 57.1 49.3 40.5 40.5 3.4% DHS 2011
Burkina
43.1 44.5 35.1 34.6 34.6 3.3% DHS 2010
Faso
57.2 55.4 53.5 49.8 51.0 47.8 47.0 43.0 41.3 41.3 3.1% DHS 2011
Bangladesh
Uganda 44.8 38.0 33.4 33.4 2.9% DHS 2011
Ethiopia 57.8 50.7 44.4 44.4 2.4% DHS 2011
ENSMI
Guatemala 50.0 54.3 43.4 43.4 2.2%
2008-09
These countries have had an annual average rates of reduction (AARR) greater than
2.2% over the last 10 years.
It is easier to build strong children than to
repair broken men

Frederick Douglass
Thank you