There is a message we need to send far and wide: We need to give our infants, toddlers and very young children a good foundation for brain development with good health and nutrition, and a safe and nurturing home and community environment for them to learn early and be successful for life.
From a public policy point of view, particularly social and health policy, this is an important part of human capital formation of a country. Healthy infants become healthy children who can grow up to be productive adults and contributing citizens who in turn will have own children of their own. This should be a virtuous cycle if civilizations is to succeed.
This essay focuses on the first five years of life and the importance of nurturing infants and young children through this phase of life safely and securely.
The brain develops fastest in the first two years of life. The stimuli an infant experiences (and neuroscience even traces this back to the fetal stage) create synapses in different parts of the brain that develop these and other parts of the brain in the process. That the infant reacts to these stimuli is a form of learning — a learned reaction that could lead to other learned actions.
With this as a framework, early childhood care and development (ECCD) specialists believe that infants and young children have an innate capacity to learn and need not wait for formal schooling to occur for learning to happen. Learning can start from the moment of birth from feeding habits (breastfeeding) and the learned behavior of seeking a mother’s warmth and nurturing.
The failure to properly provide and care for infants and young children can leave them with handicaps for life. The Lancet medical journal wrote: “The burden and cost of inaction is high…at risk of suboptimal development due to poverty and stunting…A poor start in life can lead to poor health, (under- or mal)nutrition, and inadequate learning, resulting in low adult earnings as well as social tensions…Because of this poor start, affected individuals are estimated to suffer a loss of about a quarter of average adult income per year while countries may forfeit up to twice their current GDP expenditures on health and education.” (The Lancet, 2016)
We start by looking at our children in their first two years of life.
What is the state of health and nutrition of Filipino infants aged 0 to 23 months?
The general state of children aged 0 to 23 months in the country needs to be greatly improved.
At least 1 of 5 children under 2 years of age are stunting. Stunting is the impaired growth and development of a child due to poor nutrition, repeated infection, and inadequate psychosocial stimulation. By operational definition, a child is deemed stunted if their height-for-age is more than two standard deviations below the WHO Child Growth Standards median (https://www.who.int/).
Among Philippine infants, this prevalence is high and doubles at 1 year old which coincides with the transition to complementary feeding. The prevalence of wasting (when an infant or child has severe weight loss) among Filipino children is at 7% where 5% is considered an acceptable level (FNRI, 2019). Around 1 in 3 suffers anemia which is a moderate to high public health concern.
8 out of 10 infants did not meet the MDD (minimum dietary diversity) requirements. 9 out of 10 did not receive appropriate complementary feeding based on minimum acceptable diet (i.e. both poor quantity and poor quality of complementary foods) (Goyena, FNRI, 2019).
The goal of SDG 2 is “To end all forms of malnutrition and hunger.” Proper nutrition should start within the first 1000 days of life with nutrition-specific and sensitive feeding.
What have been the trends?
Stunting begins to be evident at 12 to 23 months where the prevalence begins to reach more than 30 percent of this group of young children, considered to be “more serious” (Goyena, 2019). More boys than girls are stunted (25.4 per cent vs 19.3 per cent). There is little difference between rural or urban (22.4 per cent vs 21.1 per cent). The poorest quintile of the population has more than twice as many stunted infants and young children as the richest quintile (29.4 per cent vs 11.4 per cent).
Wasting rose from 6.6 per cent to 7.7 per cent.
Another indicator of health and wellbeing is the absence (or presence) of Anemia. Anemia is a condition where the body lacks enough healthy red blood cells to carry oxygen to a body’s tissues. A sign of anemia is body weakness and tiredness. The most common form of anemia is linked to low iron intake. This can be addressed by eating more iron rich food (mashed vegetables, mashed fish, meat). The prevalence of anemia among children under 2 years old was 29.3 per cent in 2019.
Health Standards for Pre-natal care to Early Childhood
- Adolescence and Adulthood: Family Planning and Peri-conditional nutrition.
- First to Third Trimester of pregnancy: Routine antenatal care and nutrition; maternal infection prevention, diagnosis and treatment; assessment of fetal health and growth; management of pregnancy complications.
- Labor and birth: Care during labor and childbirth; management of birth complications; immediate newborn care.
- Neonatal care (first week to first month): neonatal disease prevention and treatment; healthy home care and nutrition; high quality early childhood care and education.
- Infancy (1-23 months): Promotion of optimal infant and young child feeding; early childhood care and education.
- Early childhood (24 to 60 months: Infectious disease prevention; detection and management of childhood illness; high quality childhood care and education.
- School age (5-10 years).
The Lancet, 2016. “Advancing Early Childhood Development: From Science to Scale”. The Executive Summary for The Lancet’s Series.
Breastfeeding as a health indicator
Breastfeeding of infants is another indicator of wellness. The Philippines has adopted the international world health standard and indicators for breastfeeding. Within 1 hour of birth, early initiation for breastfeeding is encouraged. This establishes a mother-child bond that is deemed important. Exclusive breastfeeding for the first 6 months is the standard and continued breastfeeding up to 2 years or beyond with mixed feeding is encouraged.
FNRI keeps data on breastfeeding as a way to monitor the health and nutrition of infants. Timely breastfeeding improved from 51.9 per cent of infants in 2011 to 74 per cent in 2019. Exclusive breastfeeding rose from 29.7 per cent in 2003 to 57.9 per cent in 2019. The percentage of infants exclusively breastfed dropped from 77.6 per cent in the first month of birth to 35.1 per cent at age 5 months. Infants exclusively breastfed from birth to 5.9 months did, however, rise from 24.7 per cent in 2015 to 35.1 per cent in 2019. 53.1 per cent of all infants were continuously breastfed for 1 year in 2019; 34.2 per cent were continuously breastfed for 2 years in 2019.
Despite these facts, the trend in the proportion of very young children meeting the Minimum Dietary Diversity (MDD) had a downward trend for children in three age groups: 6-11 months, 12-17 months, and 18-23 months. In 2019, only 20.1 per cent of very young children met the MDD.
Children aged 6-23 months meeting the Minimum Acceptable Diet (MAD) was also low in 2019. Only 4.4 per cent of very young children aged 6-11 months old met this threshold rising to 15.4 per cent for 18-23 month old babies. The pattern was similar whether the family was rich, middle class, or poor.
Nutritional status of pre-school children
The FNRI released its Expanded National Nutrition Survey Results for Filipino Pre-School Children in 2019. Undernutrition (underweight) remained at 19 per cent – “medium severity” based on the global cut-off for public health significance.
The prevalence of stunting decreased by 1.5 percentage points but remained a “medium to high” public health problem. Wasting prevalence was within the “acceptable to poor” public health significance. On the other hand, data also recorded overweight children and obesity though not large in number.
Anemia decreased but remained a “mild” public health problem.
Undernutrition remained prevalent among those residing in rural areas and belonging to the poor and poorest households.
In general, the nutritional status of preschool-age children had improved as indicated by the downward trends, but this was still too slow to meet the SDG Goals of the country.
For children aged 0-59 months (i.e. up to 5 years old), the percentage stunted decreased from 33.8 per cent of all kids in 2003 to 28.8 per cent in 2019. This was an improvement but still unacceptably high. The percentage of underweight children in the same age group went from 20.7 per cent in 2003 to 19.0 per cent in 2019 – a slight but perhaps negligible improvement given the time span.
There is a disturbing trend that needs to be addressed. From 0 months (birth) to 5 months old to 24-35 months, young children are increasingly becoming underweight. At 0-5 months, 7.5 per cent were underweight (2019). By 24-35 months, this was 21.6% and stayed around there at 48-59 months. This was slightly lower in 2019 than 2018 for infants but the same by the time they reached 2 years of age.
By sex, girls were slightly worse than boys (19.4 per cent versus 18.6 per cent (2019).
By place of residence, rural children were worse off than urban children (20.2 per cent versus 17.1 per cent).
By wealth status, the poorest quintile was 3.7 times more likely to be underweight than the richest quintile (27.3 percent versus 7.4 per cent).
Stunting is a real problem. By 12 months onwards, over 30 per cent of all kids are stunted – too high a percentage. Boys slightly more than girls (29.5 per cent versus 28.1 percent), more rural kids than urban, but the same ratio by wealth though at a higher percentage rate (42.4 per cent for the poorest quintile).
Nutritional status of Filipino school-age children
Once undernourished, underweight or malnourished in pre-school, children enter early primary in a similar condition. The prevalence of malnutrition increased from 2018 to 2019. Anemia prevalence remains to be a “mild” public health problem and has slightly decreased in magnitude. Undernutrition remains evident among children in the rural areas and of households in the poorest and poor wealth categories.
For 5 to 10 year olds, there has some been improvement in underweight (31.9 per cent in 2003 to 26 per cent in 2019) and in stunting (36.4 percent to 25.2 per cent). This is still high, but improving.
Trends hold except more boys than girls are underweight by a larger margin (28.1 per cent versus 23.8 per cent).
Wasting appears to be a growing problem. 5.8 per cent of 5-year old children entering Kindergarten were wasted in 2019 as compared to 9.6 per cent for 9-10 year olds in that same year. Here, school feeding programs should be utilized to arrest this situation.
Government assistance through the 4Ps program
To boost human capital development in the country, the Government set up a conditional cash transfer program focusing on pre-natal and early childhood health, and basic education.
Since the pilot project involving 6,000 households in 2007, the rollout in 2008 involved 300,000 households in 2008. By 2019, the program serviced 4.4 million households or 22 per cent of the population. A total of PhP 89 billion (USD 1.7 billion) was budgeted annually of which PhP 82 billion were grants (the rest being operating expenses).
Pregnant and lactating mothers are given monthly allowances of PhP 500 to take care of the nutritional needs of themselves (during pregnancy) and their newly-born children (monthly checkups). The families of school-age children attending public schools regularly (at least 85 per cent attendance each month) can receive a P300 cash transfer each month for Elementary school, PhP 500 for Junior HS per month, and PhP 700 for Senior HS, for up to 3 children per family.
Called the Pantawid Pamilyang Pilipino Program, which roughly translates into “building bridges for Filipino families” (Schelzig 2015), 4Ps was designed to assist the poor by directly providing them with money which would be downloaded if conditions were met by households (hence “conditional cash transfers”). For pregnant women and lactating mothers, the conditions included taking children for regular clinic visits for basic health services such as immunization and growth monitoring. Mothers were required to also regularly attend sessions where they discussed such topics as family planning, good citizenship, and financial literacy (Kandpal et al., 2016).
Cash transfers were made directly to households, after which they could spend the money as they saw fit. The objective was not only to ease financial hardship but also to enable and motivate Filipino families to raise the educational and health status of their children (Orbeta Jr. and Paqueo, 2016).
The system proved to be quite accurate in directing program resources to the right targets. An assessment in 2017 found that 77 per cent of beneficiaries were from the bottom 40 percent of the population and 46 percent were from the bottom 20 percent of the population. In 2015, the government conducted new household assessments to update the database, with a target of reaching 75 percent of all households in the country (World Bank, 2015).
4Ps program results
Research found that the program had increased the average height of beneficiary children in the program and lowered the incidence of severe stunting among 6 to 36-month old children by 10.2 percentage points below the mean rate of 24 percent in control areas. Additionally, program-enrolled children were more likely to have received health services in the previous six months, such as growth monitoring, vaccination, and treatment for fever, cough, or diarrhea (Kandpal et al., 2015). Data on human development indicators for the country’s 17 regions and wealth quintiles also showed that some of those inequalities had narrowed significantly since the program began (King, 2020)
In 2019, a law institutionalized the 4Ps and named it as the country’s official poverty reduction strategy. (Information from the Pantawid Pamilyang Pilipino Program website: https://pantawid.dswd.gov.ph)
The effects of the COVID-19 pandemic and no face-to-face schooling on the nutritional levels of very young children
The continued lockdown and the Government’s order for no face-to-face in-school instructions is expected to have a major effect on early childhood development, though the long-term impacts are still too early to predict.
From November 3 through December 3, 2020, the Food and Nutrition Research Institute (FNRI) ran a Rapid Nutrition Assessment Survey in nine selected areas around the country. 3 sites were high COVID-risk areas (all urban); 3 were medium risk (all were in provinces); 3 were low risk (city or province). Mothers, caregivers, and heads of household were interviewed covering 7240 respondents for 2012 children aged 0-12 years, plus 148 pregnant women.
16.7 per cent of respondents had lost jobs; 16.5 per cent said they had other work opportunities.
62 per cent reported that they and their families experienced moderate to severe food insecurity and worried about having enough food to eat, ate less, were unable to eat healthy food, ran out of food, skipped meals, or did not eat at all.
The highest impacts were on households with children (74.7 per cent) and with pregnant members (80.8 per cent).
Pre-pandemic versus pandemic health and nutrition programs saw a drop in participation for the former to the latter. The program around child-weighing (OPT) fell from 83 per cent to 51.1 per cent participation. Supplemental feeding dropped from 21.6 per cent to 11.9 per cent; Vitamin A supplementation from 65.4 per cent to 54.9 per cent; deworming from 60.4 per cent to 35.3 per cent.
The main reasons given: No visits to the health center (51 per cent); No barangay health worker (BHW) available (35.5 per cent); or, Did Not Know (12.4 per cent).
The majority of the children did not receive supplementary feeding in high risk areas (91.4 per cent), in medium risk areas (85.3 per cent) or in low risk areas (89.1 per cent). Only 11.9 per cent of households with children aged 6 months to 12 years received family food packs consisting of packed food, cooked food or dry rations (rice, noodles).
Only 10.6 per cent of surveyed households received micronutrient powder to add to cooked food.
During the survey period, adults reported that 2 out of 10 children had lost weight, mostly in the medium risk group. But there was a higher proportion of weight loss in the severely food insecure group.
This is a snapshot of one time period and much more survey data needs to be collected before any conclusions are made. Worrisome, however, is that if this lockdown continues in low and moderate risk areas, very young children’s health and nutrition will be compromised with probable long term effects on Learning and schooling.
Community feeding for very young children with the necessary precautions should be done. Local governments who should know local conditions and behaviors should take the lead and lead responsibly in these cases.
The Department of Social Welfare and Development (DSWD) should mobilize its 4Ps network to ensure that the gains of the past are not lost through inaction. The Department of Education (DepED) should the billions of pesos in school feeding money to work with LGUs on setting up a network of community kitchens to provide hot cooked, nutritious meals to children in the pre-elementary years and early primary years (Kindergarten to Grade 2-3). This is not the time to worry about such a program not being delivered in schools. Just as in-school education has become distance education in the community, the school feeding program should be moved to the community with the help of LGUs.
This should be a temporary arrangement. But with more and more delay because of government inaction in opening schools to face-to-face interaction, even when the risks are low in many areas, every delay can have more and more permanent consequences on the development of children and their Learning.
The importance of early childhood care and development
Early childhood care and development (ECCD, also known as ECD, is an important building block in human capital formation. A good start in health and nutrition of infants and very young children will go a long way to developing their brains and with it their physical, cognitive, socio-emotional and language development, from birth to eight years of age (The Lancet, 2016).
This cannot be stressed enough.
Former NEDA Director General Ernesto Pernia wrote in a note to me: “…early child development (ECD) is the more general/widespread critical problem in terms of children achieving their full human potential. ECD is to be addressed in a number of ways: unintended or mistimed pregnancies, teenage pregnancies, gestating women/girls lacking adequate nutrition, and infants (having poor nutrition) as well…there are interventions (that) can effectively help in dealing with the massive problem of child stunting in the 0 to 5 years of age” (May 2021).
The SDG Goal for children is to give every child regardless of where they are or what their state in life is a better than fair chance at succeeding. The goal should include helping develop strong brain architecture of babies and toddlers that gives them a head start on early learning. This requires dependable interaction with nurturing adults and a safe environment for them to grow up in and explore.
Juan Miguel Luz is a fellow of FEU Public Policy Center. He is also a former DepEd Undersecretary.