All children surviving and thriving: re-envisioning UNICEF's conceptual framework of malnutrition
Authors: Maureen M Black, Chessa K Lutter, Angela C B Trude
Journal: The Lancet Global Health (2020)

Building on the successes of child survival over the past three decades, including a 56% reduction in child mortality,1UNICEFThe state of the world's children. children, food and nutrition: growing well in a changing world. UNICEF, New York, NY2019Google Scholar we are proposing a revision to UNICEF's conceptual framework of malnutrition and death. The framework, developed in 1990, was innovative and highlighted not only the dual roles of inadequate dietary intake and disease as direct causes of malnutrition, but also that the intermediate and underlying causes of malnutrition are multisectoral and extended to human, economic, and organisational resources, influenced by global, national, or local political and ideological factors and economic structure.2UNICEFPolicy review. Strategy for improving nutrition of children and women in developing countries.http://www.ceecis.org/iodine/01_global/01_pl/01_01_other_1992_unicef.pdfDate: 1990Date accessed: April 8, 2020Google Scholar Over the past 25–30 years, the framework has been revised to reflect advances in knowledge and priorities in child health and nutrition.3UNICEFImproving child nutrition: the achievable imperative for global progress. UNICEF, New York, NY2013Google Scholar As a result, it has served as a catalyst for policies, programmes, and research that have advanced health and nutritional practices worldwide, contributing to the child survival successes and substantially reduced prevalence of childhood underweight, wasting, and stunting. The adoption of the Sustainable Development Goals (SDGs) has brought global recognition that the future health, prosperity, peace, and freedom depend not only on children surviving, but also thriving.4UNTransforming our world: the 2030 agenda for sustainable development.https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdfDate: 2015Date accessed: April 8, 2020Google Scholar In addition to requiring support for child health and nutrition, thriving also includes the ability of children to form relationships, learn, take on responsibilities, and ultimately to establish a family, provide economic stability, and contribute to society. To build the broader skills of thriving, children require opportunities for responsive relationships and opportunities to explore and learn, within a secure and safe context. Thriving occurs first and foremost within the most proximal setting: the family. Throughout childhood and adolescence, children depend on their family for guidance, protection, and support. The nurturing care that children receive early in life provides the basis for responsive relationships throughout childhood, adolescence, and beyond, based on trust, mutuality, and respect. However, broader systems are also in play. Families, including children and adolescents, are dependent on their communities for social norms for cultural and behavioural issues, and for services, such as the health and education systems. Effects on families' daily life extend to distal forces, including politics, ideology, pandemics, economics, and, increasingly, the climate.5Watts N Amann M Arnell N et al.The 2019 report of the Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (639) Google Scholar Thus, in addition to improving diet and reducing disease, as outlined in the UNICEF framework, children require a comprehensive, multisectoral system of services and opportunities. Nurturing Care, a dynamic systems model introduced in the 2016–17 Lancet Series, Advancing Early Childhood Development: from Science to Scale6Black MM Walker SP Fernald LC et al.Early childhood development coming of age: science through the life course.Lancet. 2017; 389: 77-90Summary Full Text Full Text PDF PubMed Scopus (1101) Google Scholar, 7Britto PR Lye SJ Proulx K et al.Nurturing care: promoting early childhood development.Lancet. 2017; 389: 91-102Summary Full Text Full Text PDF PubMed Scopus (678) Google Scholar, 8Richter LM Daelmans B Lombardi J et al.Investing in the foundation of sustainable development: pathways to scale up for early childhood development.Lancet. 2017; 389: 103-118Summary Full Text Full Text PDF PubMed Scopus (396) Google Scholar and incorporated into the Nurturing Care Framework by WHO and partners,9WHONurturing care for early childhood development: Linking survive and thrive to transform health and human potential.https://www.who.int/maternal_child_adolescent/child/nurturing-care-framework/en/Date: 2019Date accessed: April 8, 2020Google Scholar represents that system. Our proposed revision, the conceptual framework of children surviving and thriving (figure), captures the essential roles of health and nutrition and the additional components of nurturing care, including responsive care, learning opportunities, and security and safety to ensure that children grow and develop to their potential. As shown in a meta-analysis, published in 2019, interventions that target children's nutrition can benefit their growth and nutritional status and interventions that target responsive caregiving and learning can promote their neurodevelopment.10Prado EL Larson LM Cox K Bettencourt K Kubes JN Shankar AH Do effects of early life interventions on linear growth correspond to effects on neurobehavioural development? A systematic review and meta-analysis.Lancet Glob Health. 2019; 7: e1398-e1413Summary Full Text Full Text PDF PubMed Scopus (64) Google Scholar However, nutritional interventions have restricted effects on children's neurodevelopment, and responsive caregiving and learning interventions have restricted effect on children's growth and nutrition.10Prado EL Larson LM Cox K Bettencourt K Kubes JN Shankar AH Do effects of early life interventions on linear growth correspond to effects on neurobehavioural development? A systematic review and meta-analysis.Lancet Glob Health. 2019; 7: e1398-e1413Summary Full Text Full Text PDF PubMed Scopus (64) Google Scholar Thus, to achieve thriving and the goals associated with the SDGs, children require attention to health, nutrition, learning, responsive caregiving, and safety and security. The conceptual framework of children surviving and thriving reflects the additional skills necessary for thriving, while retaining the basic structure of the original framework, with a strong emphasis on proximal and distal environments. With our proposed revisions, the conceptual framework is well positioned to advance the policies, programmes, and research necessary to attain the SDGs by promoting both surviving and thriving. The linkages with the Nurturing Care Framework support action, through a roadmap for thriving that involves caregivers, national governments, civil society, health and educational institutions, and service providers in the development and implementation of multisectoral programmes and policies within countries. Equity is operationalised within the Nurturing Care Framework by ensuring that children receive all components of the framework, with additional support when needed, on the basis of the principle that no child is left behind. Challenges posed by underweight, overweight, wasting, and stunting, along with children not reaching their developmental potential are widespread and have long-term negative consequences to the individual and society. Implementation of multisectoral programmes as proposed by the Nurturing Care Framework requires collaboration across sectors and attention to policies, finance, and governance, in parallel with workforce development and stakeholder involvement. A strong evidence-based conceptual framework is an initial step to guiding policies and programmes that will enable all children to survive and thrive. We declare no competing interests.