SPECIAL ARTICLE

Nurturing Care for Early Childhood Development: Global Perspective

and Guidance
BERNADETTE DAELMANS,1 SHEILA ASHIFA MANJI,1 NEENA RAINA2
From 1Child Health and Development Unit; Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health
Organization, Geneva, Switzerland; 2Reproductive, Maternal, Newborn, Child and Adolescent Health and Healthy Ageing, World
Health Organization, Regional Office for South-East Asia, New Delhi, India.
Correspondence to: Dr Bernadette Daelmans, World Health Organization 20 Avenue Appia, 1211 Geneva 27, Switzerland.
[email protected]

To develop to their full potential, all children need to receive nurturing care. This means that, starting in pregnancy, they are raised in a
stable environment that is sensitive to their health and nutritional needs, with protection from threats, opportunities for early learning, and
interactions that are responsive, emotionally supportive, and developmentally stimulating. Nurturing care ensures the foundations are
laid early in life for an individual to survive and thrive. Yet, at least 250 million children younger than 5 years worldwide are at risk of not
reaching their developmental potential, having major implications for their health, education, productivity and well-being along the life
course. Primary health care services provide a platform for universal support to all families and children, and an entry point for early
identification and interventions for families and children with additional needs. Healthcare providers, including pediatricians, are
uniquely well placed to watch and learn about the strengths and vulnerabilities of a family and a child, open the dialogue about the child’s
development, and support caregivers in providing their children nurturing care. Evidence shows that when caregivers are supported to
provide all components of nurturing care, starting from pregnancy, children have a better chance to unlock their developmental potential,
even when faced with adversities. This paper outlines how the Nurturing Care Framework and its five strategic actions guide multi-
sectoral policies, interventions and services. It articulates the important role the health sector can play in supporting young children’s
development in the early years.

S
urvive, thrive and transform are the objectives of environment that provides adequate nutrition, stimulation
the UN Secretary General’s Global Strategy for and protection. If the brain fails to be stimulated
Women’s, Children’s and Adolescents’ Health appropriately, the formation of neural connections will be
(2016-2030) [1]. While substantive progress has impaired, and the brain structure and function will be
been made in tackling under-five mortality, with a reduction damaged. Epigenetic changes occur that have negative
in the number of childhood deaths from 12.6 million in 1990 consequences on a person’s abilities and that can be
to 5.2 million in 2019, many children who survive are not able transferred into the next generation.
to thrive. Globally, at least 250 million children younger than
A solid foundation is laid early in life when children
5 years are at risk of not reaching their developmental
receive nurturing care. This means that they are raised in a
potential, having major implications for their health, edu-
stable environment that is sensitive to their health and
cation, productivity and well-being along the life course [2].
nutritional needs, with protection from threats,
Poverty, food insecurity, gender inequity, violence, environ-
opportunities for early learning, and interactions that are
mental toxins and caregiver’s mental health are among the
responsive, emotionally supportive, and developmentally
risk factors that affect early childhood development,
stimulating (Fig. 1a) [2,3]. Nurturing care can also restore
starting from conception. These risks often coincide at the
optimal development when there is adversity. It protects
level of the family and the child, and have cumulative
children by lowering their stress levels and encouraging
impacts as child-ren grow older [3].
emotional and cognitive coping mechanisms. It is especially
The foundations for an individual’s life-long health, important for children with developmental disabilities and is
cognitive development and social wellbeing are laid down also effective in preventing child maltreatment. Parents and
early in life. Within the developing brain, neurons start to other care-givers are at the center of providing nurturing
form within days of conception and by 4 weeks of gestation care for young children. To do so, they need knowledge,
up to 250,000 new cells are being formed every minute. In the time and resources. Supportive communities, services and
third trimester of pregnancy, the brain starts to wire itself, policies are essential to create the enabling environments
making connections between neurons through synapse that allow caregivers to appropriately care for their young
formation. This wiring is dependent on a supportive children (Fig. 1b).

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DAELMANS, ET AL. GLOBAL PERSPECTIVE ON NURTURING CARE

Source: World Health Organization, United Nations Children’s Fund, World Bank Group. Nurturing care for early childhood development: a framework
for helping children survive and thrive to transform health and human potential. Geneva: World Health Organization; 2018

Fig. 1 (a) Components of nurturing care; and (b) Enabling environments for nurturing care [1].

Unfortunately, too few children receive even the most Role of the Health Sector in Supporting Nurturing
basic interventions to support their optimal development. Care
Globally, the exclusive breastfeeding rate is less than 50%
From pregnancy to the time children enter formal education,
and almost 22% of children under five are stunted. In
the health sector is uniquely well positioned to support
countries with available data, 3 out of 4 children are exposed
caregivers in providing the five components of nurturing
to violent discipline, and less than half receive responsive
care (Fig. 1). Many interventions that support child survival
care by adults in their home. These risks are distributed
across the globe, but they are most prominent in low income
countries in South-East Asia and sub-Saharan Africa [4]. Box I Three-tiered System of Support for Early Childhood
Development
THE NURTURING CARE FRAMEWORK
Universal support
The Nurturing Care Framework, launched alongside the Antenatal care, childbirth and postnatal care, immunization, and
World Health Assembly in 2018, provides a roadmap for well child and sick child outpatient care are available in all
action [5]. It builds on state-of-the art evidence and proposes countries and they provide excellent opportunities for supporting
nurturing care, including by integrating missing components such
five strategic actions to facilitate a whole-of-society and responsive caregiving and caregiver support for the general
whole-of-government approach for every child to receive population.
nurturing care. In so doing, all children will be supported to Targeted support
survive, thrive and reach their full developmental potential. When families are affected by risks such as poverty,
The framework is accompanied by multiple global assets, undernutrition, HIV, teenage pregnancy, violence, displacement or
including illustrative country examples, to help facilitate its humanitarian emergencies, young children are at risk of sub-
optimal development. They need targeted support that can be
operationalization [6]. provided by home visits, parent groups, and additional facility-
Strengthening services is one of the five strategic based support. Digital communication can be used to provide
caregivers with parenting tips and telephone helplines can assist in
actions of the Nurturing Care Framework and it pertains to solving problems. Targeted support also provides opportunity to
systems, workforce and services in health and other sectors. link families with other services, like social welfare.
All caregivers need some support for nurturing care, but not Indicated support
all families need the same intensity of support. The framework Globally, an estimated one in six children is living with a
proposes a three-level approach of universal, targeted, and developmental disability. Yet, many countries are challenged to
indicated support (Box I), to meet the needs of all children provide services, starting with infant and family-centred
and their families, with incremental support for those at risk of developmental care in the neonatal period. Investing in workforce
capacity and services for indicated support for children with
developmental delays, or with additional needs such as due developmental difficulties or disabilities should also be a priority.
to developmental disabilities. Identifying the available entry Building a three-tiered system: Frontline workers in health
points in contacts that caregivers and young children have facilities and community health workers can be the cornerstone of
with services is a feasible and cost-effective way for getting systems that identify children with developmental disabilities and
started to strengthen a three-tiered system of support. provide interventions early.

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have a direct impact on early childhood development. young children. When implemented with quality, they have
Quality antenatal care, essential newborn care, kangaroo shown to improve caregiving practices and learning
mother care for premature and low birth weight infants, opportunities in the home, protect children from harsh
exclusive breast-feeding and appropriate complementary physical punishment, abuse and neglect, and improve
feeding, immunization, and timely management of childhood children’s developmental outcomes [3].
illness are all essential. Pre-conception care enables
New data have also illustrated that the intelligence
prospective parents to prepare for future parenthood, by
quotient scores of adolescents of a cohort of pre-school
adopting healthier lifestyles, accessing essential
children who were living in impoverished communities and
interventions such as for anemia, and developing stronger
were raised in a nurturing home environment, were on
health literacy.
average 6 points higher, compared to children who did not
Nonetheless, isolated biomedical interventions alone are benefit from this nurturance [7]. Stunted children whose
not enough. Health and nutrition services need to address all caregivers received support for responsive caregiving and
components of nurturing care including interventions for early learning activities, had an estimated 25% increase in
responsive caregiving, early learning activities, safety and earnings in adulthood compared to those who did not
security, and supports to caregivers (Box II). WHO and receive the intervention, putting them at par with non-
UNICEF developed the Care for Child Development (CCD) stunted peers [8].
package to equip health care pro-viders with the knowledge
Pediatricians have a critical role to play. They can provide
and the skills to support caregivers in responsive caregiving
support for all components of nurturing care in their routine
and early learning activities, through age-specific
practice and engage in transdisciplinary care for those
recommen- dations of communication and play with the
families and children that need indicated support.
child. The Caring for the Caregiver (CFC) package is a
Pediatricians can watch and learn about the strengths and
complementary set of materials focusing on the social and
vulnerabilities of a family and a child, open the dialogue
emotional well-being of caregivers. The interventions
about the child’s development, and support caregivers in
underpinning CCD and CfC have been integrated into health
providing nurturing care for the child. They can ensure that
services in multiple settings and government programs
inpatient neonatal and pediatric care services provide a
across the world; they have helped primary care workers and
positive experience for children and their caregivers, and that
pediatricians to strengthen their support for families and
standards for developmentally supportive care are met. This
support is important in their interactions with every family
Box II Strengthening Caregiver Capacity to Provide and every child, but especially so for children who are at risk
Nurturing Care of sub-optimal development or have a developmental
Responsive caregiving disability.
Responsive caregiving is about the caregiver’s ability to notice, FROM EVIDENCE TO IMPLEMENTATION AT SCALE
understand, and respond to their child’s signals appropriately.
Caregivers who are sensitive have frequent mutually enjoyable The evidence for nurturing care is compelling but at present,
interactions with their children, which help young children to
understand the world around them and to learn about people,
many countries are challenged to implement relevant policies
relationships and language. and services at scale. Examples of good practice have mostly
Opportunities for early learning emanated from high income countries and they have usually
As soon as babies are born, they begin to learn through their been informed by a strong commitment of the government to
interactions with other people. Daily routines provide ample reduce inequities. The ‘Chile grows with you’ program – or
opportunity for early learning activities. Smiling and eye Chile Crece Contigo – is often cited as an example of a whole-
contact, talking and singing, modelling and imitation, and of-government approach to address young children’s
simple games like “wave bye-bye” support early learning.
Playing with everyday household items like cups and pots development. It started small with strengthening antenatal
helps children learn about objects and their functions. Reading care and progressively invested in other services along the
books allows children to learn that objects have names, as well continuum of care while making available social benefits to
as build curiosity, imagination and knowledge. vulnerable families. Through a high-level governance
Caring for the caregiver mechanism, roles of different sectors were clearly defined,
An estimated one in five women experiences signs of perinatal and resources made available to each sector, with
depression globally and many women routinely face the stress
of caring for resource-constraint households. By applying tech-
accountability for results at every level of the system. India’s
niques for management of relationships, stress, conflict and Integrated Child Development Services (ICDS) program is
resources, providers can connect with and support caregivers another exemplar of government commitment to early
to address their problems, which in turn helps caregivers childhood development. While initial efforts focused on
connect and support their young children.
children beyond infancy, its reach and impact are currently

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being amplified by the contribution of the National Health continuing education of existing work force, requires the
Mission that has the capacity to work with families and availability of a dedicated group of experts who are well
young children starting from pregnancy and in the first years trained themselves. Pediatricians can be at the forefront of
of life, through home visits and community services. From capacity building, as trainers, mentors and supervisors. But
these and other examples, lessons have been learnt that can not only is it important to strengthen skills, attention is also
inform the five strategic actions. needed for how services are organized in a health facility and
community, the triage and management of patient flows, and
Strategic Action 1: Lead and Invest
the time that is available for counselling on nurturing care.
To improve children’s holistic development, inputs are Coordination between different disciplines is essential,
needed across a range of sectors, through policies, services, especially for children with additional needs, and pediatri-
infrastructure and information. Examples of policies are a cians can be at the center of organizing transdisciplinary care
minimum wage, universal health coverage, family-friendly to ensure all such needs are met.
policies in the workplace, and affordable childcare services. Strategic Action 4: Monitor Progress
It is important for governments to set up functional
governance and coordination mechanisms, at national and Improving developmental outcomes is the goal and policy-
sub-national levels, to facilitate multi-sectoral collaboration, makers will be eager to see results. However, the benefits
including public and private sector entities. The develop- from investing in nurturing care for early childhood develop-
ment of a national policy that reflects a common vision, goals ment manifest themselves progressively and it can be
and targets, and specifies the roles of different sectors and dangerous to look for quick wins. To develop strategies and
stakeholders, has shown to be helpful to accelerate actions in approaches that respond to local context and are effective,
support of early childhood development. Increases in scalable and sustainable, it is recommended to start small,
financing are needed in each sector to add activities to monitor and learn, and make adaptations in rapid, iterative
ongoing efforts, and efficiency gains can usually be made cycles. Inputs, outputs and outcomes in all five domains of
through improved collaboration. Health care professionals nurturing care need to be tracked and improvements
can make an important contribution to these actions, as documented, as they are a precursor to changes in children’s
champions, experts and practitioners. For example, pedia- developmental status.
tricians and pediatrics associations can advocate for policy The ECD working group of the Countdown to 2030 has
change, participate in national technical advisory groups, brought together country profiles with 42 indicators to
and be part of the dialogue regarding multisectoral policies support the implementation of the Nurturing Care Frame-
and plans for investing in early childhood development. work. Available for 193 countries, profiles include the Early
Strategic Action 2: Focus on Families and Their Childhood Development Index 2030, which is a global
Communities measure to assess progress on SDG target 4.2, indicator 4.2.1
Proportion of children who are develop-mentally on track
As nurturing care is so embedded within the lives of each in health, learning and psychosocial wellbeing, by sex.
family and child, communities themselves can play a major Population-based surveys, such as the Multiple Indicator
role in creating enabling environments that benefit both Cluster Survey and the Demographic and Health Survey, are
caregivers and young children. Understanding the values important sources of data that can be used to strengthen
and strengths of the community and enabling community programming and sustain advocacy, and health
participation is key for feasibility, effectiveness and professionals need to consult these.
sustaina-bility of strategies that address early childhood
development. A strong partnership between community and Strategic Action 5: Use Data and Innovate
facility-based services is essential for continuity of care. Further research is needed to unpack the evidence behind
Healthcare professionals at all levels of the system carry improving early childhood development but rather than
responsibility to make this happen. They can link families to investing in efficacy studies, more efforts are needed to
existing services in the communities, help cultivate support conduct effectiveness and transition-to-scale implemen-
networks, and identify and bring visibility to local tation research. This will help countries to develop appro-
champions. priate models of care that are feasible for implementation at
scale, build capacities for implementation, and obtain
Strategic Action 3: Strengthen Services
context-specific cost data. It will also support identification
Strengthening the capacity of the workforce and building the of innovative solutions to increase access, quality and
three levels of support requires substantive efforts. The coverage of services. Point-of-care quality improvement
early integration of nurturing care relevant content in pre- approaches in pediatric health services can make an impor-
service education, complemented by in-service training and tant contribution in this respect, as exemplified by the

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KEY MESSAGES
• Early childhood lays the foundation for health, well-being, learning and productivity throughout the life course.
• To optimally grow and develop, children need to receive nurturing care and caregivers need to be supported
to provide it, starting from pregnancy.
• National policies, interventions and services are needed to create the enabling environments for parents and
other primary caregivers to provide nurturing care.
• The health sector has an important role to play and pediatric services are well placed to facilitate adequate care
for all children, and particularly those with developmental disabilities.
• The COVID-19 pandemic has increased the urgency to invest in nurturing care as it has propelled millions of
families into poverty and created a global crisis in learning in childhood.

adoption of national operational guidelines for Family a child’s life, health professionals can make an important
Participatory Care in neonatal care units in India; they should contri-bution to ‘building back better’ and creating a more
be an integral part of service delivery, be well-documented, sustainable world for all.
and results of successes (and failures) shared through
Note: The authors are staff members of the World Health
professional networks, communities of practices and Organization. The authors alone are responsible for the views
scientific journals. expressed in this paper and they do not necessarily represent the
These and other challenges have been addressed in the decisions, policy or views of the World Health Organization.
nurturing care handbook, a guide to support the implemen-tation Contributors: BD: conceived the manuscript and developed the
of the NCF in accordance with the five strategic actions [9]. first draft; BD, SM: revised sections of the manuscript. All authors
CONCLUSIONS approved the final version of manuscript.
Funding: None; Competing interests: None stated.
A decade is left for countries to achieve the sustainable
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