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According to the most recent estimates from the Lancet series on early childhood development, 250 million children under the age of five in low and middle-income countries suffer from stunting and extreme poverty, putting them at risk of poor developmental outcomes. If current trends continue, by 2025 the number of stunted children will be cut by only 20 percent, just half of the target set by the Sustainable Development Goals (SDGs).

¡°The economic costs associated with stunting can be quite high,¡± said Asli Demirguc-Kunt, Director of Research at the World Bank, at a Policy Research Talk on the topic. ¡°Stunting affects brain development, lowers cognitive and socio-emotional skills, and also leads to lower levels of education and income.¡±

According to Emanuela Galasso, a Senior Economist at the World Bank, the high and permanent costs associated with stunting make the case for investments in early childhood development compelling. The brain undergoes critical phases of development in the first two years of life, and children pay a life-long price if this window is missed. But Galasso pointed out that it¡¯s not only adequate nutrition that is required for children to reach their full potential, but also protection from infections and toxins as well as early stimulation.

While the challenge is complex, the World Bank and its partners are accumulating a growing body of evidence on how countries can implement effective programs to prevent stunting and promote early stimulation.

According to estimates, a package of interventions targeted to the first 1,000 days of life in 34 countries¡ªincluding salt iodization, nutrient and complementary feeding supplementation for pregnant women and children, and nutrition education¡ªcould reduce the global rate of stunting by 20 percent. While not sufficient by itself to reach the SDG goal, the estimated rate of return on this investment would be 17 percent¡ªa compelling figure when compared to other potential uses of limited development resources.  

But Galasso warned that trying to maintain quality while scaling up existing programs to achieve widespread coverage can pose a significant challenge. When a community-based nutrition program in Madagascar doubled in size between 2007 and 2011, the expanded program failed to have any impact. Both a reduction in the quality of frontline workers and a deterioration in the quality of training were identified as possible reasons for the lack of impact.

¡°Increasing coverage by itself does not translate into impact if you don¡¯t focus on quality,¡± said Galasso.

Peru¡¯s nutrition program provides a hopeful counterexample: the country halved stunting in seven years with support from the World Bank. Critical ingredients in Peru¡¯s success included performance-based budgeting, careful planning, and geographical targeting of the supply of health services coupled with interventions to promote demand.

Programs that promote early stimulation can further reduce the long-term cost of stunting and enhance the returns to nutrition interventions. Home visits that build parental skills, as well as group parenting initiatives that encourage peer support, have been shown to have sizable effects on child development in small-scale studies. Yet there is little research about how these types of initiatives can operate effectively at scale.

ľ¹ÏÓ°Ôº and a number of partners are conducting a randomized control trial in Madagascar to test combinations of nutrition counseling, preventive nutrition supplementation, and early stimulation. Due to be concluded in 2017, the study will provide a better understanding of the optimal timing and duration of various interventions, as well as the joint benefits of delivering nutrition and early stimulation programs together.

Another major area of research still to be tackled: identifying the complementarities between nutrition and early stimulation programs, on the one hand, and policies on water and sanitation, social protection, and agriculture, on the other. Designed appropriately, combinations of these policies may be able to deliver more than the sum of their parts.

Galasso also argued that a necessary component of any successful early childhood development program is behavioral change. Social norms often inhibit optimal child-rearing practices. In Senegal, for example, the Tostan Reinforcement of Parental Practices program addressed a norm against talking to babies through a combination of group parenting sessions and home visits. Caregivers who took part in the program changed their beliefs about the importance of talking to their babies, although this did not translate into changed practices in their daily lives. More experimentation is needed to better tailor such interventions to local contexts.

¡°Early childhood development is one of the most overlooked obstacles to development in our partner countries,¡± said Keith Hansen, Vice President for Human Development. ¡°The number of permanently stunted children is as important a future predictor of economic performance as many of the things that routinely get measured and reported in The Economist.¡±