Vaivada and colleagues extend previous work in The Lancet Early Childhood Development (ECD) Series and recommend interventions to support child development in low- and middle-income countries (LMIC).1 As the authors rightly noted, the frequently reported estimates of ∼250 million children who are younger than the age of 5 years and at risk for suboptimal development are attributable solely to stunting and extreme poverty. It is, therefore, not surprising that our overwhelming focus in this review is on nutritional interventions and infection control from preconception and pregnancy until the age of 5 years.
The value of these interventions for all children is unquestionable. However, unlike the Millennium Development Goals, the prevailing Sustainable Development Goals (SDGs) mandate a disability-inclusive approach to ECD. In the fourth SDG, for example, actions to ensure inclusive and equitable quality education and promote lifelong learning opportunities for all children are specifically called for, including monitoring the proportion of children younger than 5 years of age who are developmentally disadvantaged. Already, prominent causes of neonatal and child mortality in LMIC, such as preterm birth, birth asphyxia, infections, malnutrition, and severe hyperbilirubinemia, are also risk factors for developmental disabilities in survivors. The paradigm shift envisaged under the SDG dispensation is meant to provide an equitable safety net for the beneficiaries of the survival endeavors.
The current, narrow narrative on ECD for LMIC, therefore, needs to be redefined beyond nutritional interventions and psychosocial stimulation to take account of the special care–needs of children with or at risk for developmental disabilities such as sensory impairments, cerebral palsy, autism spectrum disorders, and intellectual disabilities. This would necessitate integrated and multidisciplinary interventions at 3 levels: primary prevention aimed at reducing the incidence of developmental disabilities by addressing the diverse biological and environmental risk factors, including stunting and poverty; secondary prevention through early detection of disabilities within the sensitive windows of developmental plasticity across all domains; and tertiary prevention through comprehensive, community-based rehabilitation programs. Several low-cost tools now exist to facilitate early detection programs for optimal rehabilitation in LMIC.2
For a start, the global burden of developmental disabilities needs to be quantified more accurately, guided by the unequivocal evidence on the architecture of brain development.3,4 This will assist in setting ECD priorities, especially in high-prevalence nations. Much progress has been made in developing epidemiologic tools for gathering population-based data on child disabilities.5 Meanwhile, robust modeling tools now exist for exploring a vast range of risk factors for child disability as demonstrated by the work of the Institute of Health Metrics and Evaluation and the Child and Epidemiology Reference Group. Thus, the former constraint on the lack of data on developmental impairments (besides cognitive deficits)5 or limited evidence from traditional systematic reviews and meta-analysis should no longer be misconstrued as evidence of the absence of the considerable, lifetime burden of childhood disability in LMIC.
A holistic and inclusive approach to ECD will not only advance the disability-inclusive SDG mandates but also begin to address the implicit and persisting violations of the United Nations Convention of the Rights of the Child and Convention on the Rights of Persons with Disabilities.
CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.