Programming

According to the well-evidenced Developmental Origins of Health and Disease concept (originally the ‘Barker hypothesis’), disadvantage in fetal life and early childhood is an important determinant of chronic disease in adulthood, in particular obesity, diabetes and heart disease.8 For example, low birth weight doubles the risk of diabetes and serious cardiovascular disease (eg, heart attack and stroke) by age 50 years.9 Mechanisms include: modifications to cytogenesis and organogenesis; changes to metabolic and endocrine responses and epigenetic effects which alter gene expression. The result is a ‘resetting’ or ‘tuning’ in early life to adapt to adversity, but with a long-term cost.

Brain development and cognition

Moore et al remind us that the brain is much more than a skull-encased set of neuronal connections, but is ‘embodied’ (intimately connected to, shaped by and influencing multiple body systems) and ‘emotional’ (emotions are an important organiser of brain development).10 Anything that adversely impacts brain development may have profound and far-reaching consequences as figure 1 shows. Babies have relatively few synapses at birth. Over the next few years, synapses develop and are refined by stimulation and experience. By the age of 6 years, ‘pruning’ starts ensuring that the most important networks of synapses grow (figure 2). The early neuroplasticity of the brain is both a strength (ability to adapt to the immediate environment) and a weakness (adaptations may have a long-term cost).10 Brain development can be adversely affected by suboptimal nutrition in early life for the reasons given above, but it is also affected by the emotional environment (secure attachment, toxic stress) and level of stimulation during this period.11

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Figure 1

Abnormal brain development following neglect in early childhood. The CT scan of the brain of a healthy child aged 3 years (left) and a child aged 3 years suffering from severe sensory-deprivation neglect (right), showing microcephaly, enlarged ventricles and cortical atrophy. Reprinted with permission from Springer Nature: Brain and Mind, Perry BD 2002; 3:79-10011

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Figure 2

Synaptic density in children at birth, 6 years and 14 years showing how synapses develop extensively in the early years and then undergo pruning to ensure the most important networks grow. Used with permission from Rethinking the Brain, New York. Families and Work Institute (1997).

Children whose development falls behind in the first year will struggle to catch up. Children under 2 years are more vulnerable to abuse and neglect, and the risk increases with substance misuse, domestic violence, mental illness and other complex family situations (which affect about a quarter of infants in the UK). A large randomised controlled trial of 233 families in Dublin found that a programme of positive parenting support from pregnancy through to age 4–5 years improved children’s development (cognitive, language, motor, social and emotional), approach to learning and their physical well-being compared with controls.12

Long-term follow-up of the well-evidenced Nurse Family Partnership programme demonstrates that early intervention results in improved academic achievement and fewer internalising mental health problems at age 12 years.7

Mental and emotional health

Since the seminal ‘Adverse Childhood Experiences’ study in 1998, evidence has continued to mount that early exposure to an adverse environment has widespread and long-lasting negative effects on mental as well as physical health.13–15 For example, lower birth weight is associated with depressive symptoms in adult life.14 Children born preterm and/or very low birth weight are more likely to have mental health and attention problems compared with peers, from childhood into adulthood.14 Early life experience, avoidance of toxic stress and ‘good-enough’ parenting, with the building of strong attachment bonds, is vital to later emotional and mental health.11

Nutrition and obesity

In 2008, a Lancet series called for a global health focus on pregnancy and the first 2 years.16 Effective interventions (eg, breastfeeding promotion, micronutrients) were highlighted that would reduce child morbidity and mortality. Progress was summarised in a further Lancet series in 2013, adding support for a focus on the first 1000 days.17 This demonstrated that effective implementation of 10 evidence-based nutrition interventions focused on young children and maternal health in at-risk countries, would reduce under-5 child deaths by 15%, stunting by 20% and severe wasting by 61%.

In high-income countries, nutrition in the first 1000 days (including maternal nutrition, obesity during pregnancy, breast feeding and early diet) has a powerful impact on later risk of obesity.18 Data from the National Child Measurement Programme show that 34.3% of children at age 11 years are overweight or obese.19 Obesity is hard to reverse once established; it is better prevented. Early intervention is key.20

A suboptimal nutritional environment (deficiency/excess of macronutrients and micro-nutrients) may have lifelong effects on brain development—the earlier this occurs, the greater and less reversible the impact.21

Economic benefits

According to the Nobel prize winning economist, Heckman, the best return on investment society can make is in the first 1000 days (figure 3).5 22 However, it is not a case of only investing early in life: investment in later childhood/adolescence maximises the chance of a good First Thousand Days for the next generation. The challenge in the current financial climate is how we can use life course data trajectories to measure effectiveness of interventions at an earlier stage. Tools such as the Early Development Instrument developed by Hertzman et al show promise, revealing links to early social and wider determinants of health.5 23 A ‘System Transformation’ approach, for example, as advocated by Halfon et al in the USA, may be a key to unlock progress through deeper understanding of the complex health and social systems within which early child health is situated.24

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Figure 3

The benefits of early investment. Source: James Heckman https://heckmanequation.org/resource/the-heckman-curve/.

UK government First Thousand Days consultation

The First Thousand Days Health and Social Care Committee inquiry outcome was published in early 2019 and reflects key points in the RCPCH submission.2 It mandates local authorities to improve First Thousand Days support through high-quality local services for children and families, incentivised by a transformation fund, and based on the following principles:

• ‘proportionate universalism’—services for all but targeted according to need;

• prevention and early intervention (with appropriate long-term, secure funding);

• community partnerships;

• meeting needs of marginalised groups;

• greater integration and better multiagency working;

• evidence-based provision.

A revised and expanded Healthy Child Programme is recommended, with increased health visiting resource, a wider family focus (not just the child, but those around the child), with preconception and pregnancy support. Although there is focus on the First Thousand Days, it is important that the programme is graded into later childhood, avoiding a ‘cliff edge’ loss of support. High-level goals are to reduce infant mortality; reduce adverse childhood experiences; increase school readiness and a focus on reducing child poverty and inequality. It calls for high-level leadership within government, joined-up working within government, and prioritisation of the First Thousand Days in policy and funding.

Initiatives in the UK

Leeds illustrates how the First Thousand days approach has informed difficult policy and funding choices in a climate of austerity, with priority given to early years investment (box 1).

At its core is HENRY, a national initiative that trains community and health practitioners to work more effectively with parents of very young children to establish healthier home environments.25 26

Wales has been implementing a similar approach in some areas since 2011, and nationally since 2015 (under the title ‘F1000D’), underpinned by national policy drivers (such as the Well-being of Future Generations (Wales) Act 2015). A First Thousand Days collaborative has been set up, with system engagement events around the country. The programme has three key objectives: 1) optimal outcomes from every pregnancy for mother and child; 2) children achieving their developmental outcomes at age 2; 3) fewer children exposed to adverse childhood experiences in the first 1000 days.

Scotland has had over a decade of emphasis on early intervention, with an explicit government policy commitment in 2008,27

and innovative quality improvement approaches to facilitate better early child outcomes. Their Children and Young People Improvement Collaborative website illustrates the success of this approach with case studies.28

‘A Better Start’ is a 10-year, £215 million programme funded by the National Lottery. It commenced in 2015 with five partnership areas across the UK.29 It focuses on improved outcomes for young children, through investment in early childhood, co-design of services with families and stakeholders and sharing learning and solutions across the network and beyond.

A number of other regions and councils are now championing a First Thousand Days approach, for example, since 2017 Croydon and Calderdale councils.