Childhood mortality in developing countries remains the most dramatic issue confronting the public health and pediatric communities; each year there are more than 8 million deaths in children younger than 5 years.1,–,3 Mortality, however, is “the tip of the iceberg”4 of the serious problems that face children in the developing world. Importantly, it is conservatively estimated that more than 200 million children younger than 5 years (∼40% of those living in developing countries) do not reach their potential in cognitive development because of problems associated with extreme poverty: malnutrition severe enough to lead to growth retardation; iodine and iron deficiency; inadequate cognitive and social-emotional stimulation; and other less well-documented factors (social risk, environmental toxins, and infectious diseases).4,5 Inadequate early childhood development leads to poor school performance, low adult incomes, intergenerational transmission of poverty, and negative impact on national development.
In this...
THINK DEVELOPMENTALLY - REFER EARLY
Alfred L. Scherzer, MD, EdD, FAAP, SUNY, Stony Brook School of Medicine, Department of Pediatrics Meera Chhagan, FCPaed, PhD, University of KwaZulu-Natal, Durban, South Africa, Department of Paediatrics and Child Health Shuaib Kauchali, FCPaed, MS, University of KwaZulu-Natal, Durban, South Africa, Department of Paediatrics and Child Health Correspondence: Alfred L. Scherzer, MD, EdD, FAAP. 15 W. 2nd St., Riverhead, NY, 11946; t 631 727-6785, f 631 727 7154; alfred.scherzer@stonybrook.edu.
We must go beyond the recent commentary which emphasizes the positive long term effects for children who receive early stimulation (1). For those with developmental delays and disabilities in need of such services the benefits of early intervention are also well documented (2, 3, 4), but unless a child can be identified early he will not receive appropriate and timely stimulation. While little is known about the current practice of regular surveillance (5), survey data indicate that children often do not receive a periodic developmental assessment (6, 7), and less than half of pediatric practitioners use formal screening tools (8). Even in a trial of the American Academy of Pediatrics (AAP) early screening algorithm, only 61% of those who failed the screening procedure were actually referred for further evaluation and possible intervention (9). In order to identify a child in special need of such intervention, each of us must accept responsibility for developmental surveillance during all clinical contacts, encourage early screening and evaluation, and assure referral for intervention (10).
It is time that we recognize the multiplicity of factors at play which affect early identification and timely provision of stimulation. Actual clinical practice often suggests insufficient training, awareness, or interest (11, 12), doubt about the value of early diagnosis and non- acceptance of early treatment (13), uncertainty concerning where and how to refer (14), time limitations of the clinic visit and inadequate reimbursement (15), and cost factors (16). Practitioners with limited training or experience may be concerned about unnecessarily alerting a family and would prefer waiting until the problem is obvious (17).
In low and middle income countries neither caregiver (18, 19, 20) nor practitioner may be aware of a developmental problem. Moreover, by training and experience general clinicians and sub-specialists often deal only with the immediate medical problem without thought of responsibility for existing developmental needs. This attitude and approach to disease eradication exclusively, without consideration and planning for quality of life of survivors, is often equally true of many government and non- government international health funding agencies now providing programs in low and middle income countries (21). Conditions under which children are dying are also often the conditions under which they are living. Child survival and child development are inseparable (22). All of these issues need to be systematically considered wherever and by whom childhood care is provided so that children in need can be appropriately referred for stimulation.
In order to assure that children in need actually receive early stimulation, we urge a two-fold model as the accepted pediatric standard for practice. This should be incorporated into all training programs. First, health workers who provide medical treatment to children at all levels and specialties should simultaneously be aware of the child's development and behavior through the regular practice of developmental surveillance. They need to THINK DEVELOPMENTALLY as an integral part of all patient contacts. It is then essential that medical staff REFER EARLY for further evaluation and intervention any child who shows delays in development
Secondly, a culturally relevant (23), simple, brief instrument can help guide developmental surveillance and monitoring (24). Such a screening device is now included, for example, in the South African ROAD TO HEALTH BOOKLET. This is a parent-held record to monitor and promote early child health, growth, and development, distributed to all new-borns at state and private facilities, and checked periodically at well child visits to primary health care services (25). It is suggested that a check- off sheet for all practitioners also be utilized regularly in clinical settings. Using culturally appropriate milestones grouped by age intervals, levels of accomplishment would be checked off either as observed or from caregiver interview. At an agreed upon level of "failures" the child would be referred for further evaluation. Field testing of such a system has been tried in Cambodia (26), and is currently underway in South Africa. It can serve as a guide or reminder to the practitioner, and could provide the basis for improved caregiver education in both developing and developed countries.
Renewed efforts are called for to more realistically match the growing population of children having delays and disabilities with appropriate early stimulation. It is also time that governments and service providers embark on a care plan for children that simultaneously integrates efforts to improve child survival and optimum child development (27). The numbers of children reaching their developmental potential would serve as a measure of the impact of these interventions (28). To achieve this end all of us who provide care for children should have a "bumper sticker" in mind as we see patients, alerting us to THINK DEVELOPMENTALLY - REFER EARLY!
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Conflict of Interest:
None declared