The first 1 000 days of a child's life hold the key to health and intellectual development. Development at a physical, intellectual and emotional level occurs the fastest from the commencement of pregnancy until the child's second birthday. During this period the brain expands by 80%, says Prof Mariana Kruger, Executive Head of the Department of Paediatrics and Child Health of the Faculty of Medicine and Health Sciences.

However, in South Africa many children are denied the right to the best care during this period. The resulting negative chain reaction resonates until adulthood, as well as in the community as a whole: Chronic malnutrition results in poor brain development, which in turn causes poor school performance and could eventually result in lifelong poverty, Kruger explains.

"Poor nutrition impacts negatively on a country's Gross Domestic Product, which could be 2% to 3% lower," she adds. "The direct cost to health world-wide is estimated at approximately $20 to 30 billion."

However, malnutrition does not necessarily go hand in hand with poverty. This is proven by the fact that countries like South Africa, Botswana and Mexico with a relative higher national wealth do not perform well in this regard, in contrast to countries like Malawi, Madagascar and Peru.

Family planning and breastfeeding

In South Africa several challenges have to be overcome and focus areas have to be developed. Little guidance is provided regarding birth control and family planning, Kruger says. "Effective birth control is necessary to prevent children in poor families from being born too close to one another."

Furthermore, birth control and family planning clinics are attended poorly. Ignorance, distance and cost play a huge part in this regard, since women have to take a day off from work to get there and are sometimes sent away because they arrive on the wrong day.

In the first 1 000 days, the health worker is often the portal to information about improved nutrition for mother and child, hygiene and curable diseases like diarrhoea.   

Exclusive breastfeeding is the single most important step for infant survival during the first six months after birth, Kruger emphasises. In fact, in developing countries such infants will have a six times higher chance of survival than children who are not breast-fed.

However, the AIDS pandemic in South Africa, coupled with fear that the HI virus can be transmitted from mother to child, contributed to breastfeeding being moved to the back-burner to a large extent. Because the government provided alternative feeding for a long time, the misperception was established that that is the way things should be done. The view even developed that "the rich" do things in that way, Kruger explains.

Dwarfism

After the first six months the infant requires access to balanced feeding. However, in sub-Saharan Africa dwarfism (poor growth lengthwise) is increasing. This is an irreversible condition which can be ascribed to chronic malnutrition during the first period. Currently more than a third of all children – 17 million worldwide – are affected by this. It is estimated that healthy nutrition until the age of 12 months can reduce this problem by 20%.

Kruger emphasises that health cannot be observed in isolation. "If we wish to save a child in his first 1 000 days, it is not only about survival, but also about development and learning. We have only succeeded if we develop a child into a self-reliant individual who eventually finds a job and is able to keep it.

Importance of reading

It astounds her that very few parents realise that they can start reading to their children before their birth in order to stimulate them. "In South Africa we do very well to prevent AIDS in babies, but scholastically not enough is done for children. In fact, many Xhosa speaking mothers don't even know that children's books exist in their own language. And we know children's education outcome is just that much better if they are introduced to books during their first two years."

Dr Miemie du Preez, a neonatologist in the same section, is of the opinion that books are just as important for a child's future as breast-feeding, inoculations and access to healthcare.

She is closely involved in a reading project at Tygerberg Children's Hospital, where medical students, nurses or other volunteers expose mothers and children of all ages to books.

Reading together (when parents read to their own children) is encouraged in several ways, even in the case of premature babies. "If it is done often, the structure of a developing brain can change," Du Preez says. "Every baby admitted to our neonatal wards receives a nursery rhyme book in their mother's native language and the parents read to them daily. A dream is to have enough books so that every child admitted to Tygerberg Hospital will leave with a picture book."

Du Preez refers to a recent study which indicates that 75% of all 5 year olds in the Western Cape are not ready for school. "We can blame the school system, but the simple truth is that maximal brain development takes place during the first three years and that lost opportunities and a lack of stimulation cannot be reversed."

Political will

In the final instance the political will must exist to implement effective strategies, Kruger says. A country's legislation, policies and regulations have to be improved to boost the first 1 000 days of a child's life. (In 2016 the Western Cape became the first province to prioritise this with its campaign "Right Beginning, Bright Future".)

Kruger once again emphasises breast-feeding as of cardinal importance. She says a mind shift is required, with mothers to be allowed to breast-feed at the working place and seats specifically for breast-feeding women to be installed in public transport.

Other low-cost solutions include good hygiene (prevents deaths due to diarrhoea), appropriate supplementary nutrition as well as supplements such as zink, iron (improves resistance to infections) and Vitamin A (prevents blindness and reduces the risk of deaths due to general child infections).

Partnerships between the public and the private sectors can help ensure that the necessary nutrition regimens for mothers and children fall in place.

In South Africa, primary healthcare clinics are nurse-driven in practice, but the enormous shortage of nursing personnel and insufficient training remain problems. "It is important to invest in health workers, especially those who are involved during pregnancy and in primary healthcare clinics. Malawi and Nepal are excellent examples, where extraordinary success is achieved by the strategic placement of health workers."

"And parents with a good education make a drastic difference," Kruger emphasises. "We have a high incidence of teenage pregnancies and mothers who don't make it to matric. Future mothers have to be able to combat malnutrition with the necessary knowledge. The ideal is that all girls should be fully schooled."