Transcript of The first 2000 days of life - Dr Elisabeth Murphy
Dr Elisabeth Murphy: Hello. My name's Elisabeth Murphy. I'm the Senior Clinical Advisor for Child and Family Health at the Ministry of Health and it's my pleasure to speak to you this morning about the importance of the first 2000 days of life. Thank you for joining me for these 15 minutes, which could actually save lives.
We all know about saving lives in the traditional way ABC airway, breathing and circulation, but now we know about the importance of a new ABC. One that is about the importance of the first 2000 days of life, that period of time from conception to the age of five, 2000 days when ninety percent of the brain is developing. 2000 days that has an impact on the next thirty thousand days of life.
So what is this new ABC? Well we'll go through the evidence of each one of these aspects: antenatal care, brain development, childhood experience and look at how that information has been supported by data and epigenetics. Beginning where it does in the antenatal period, we'll talk to three aspects.
The first: physical health. We've long known the importance of the physical health of the mother on the physical health and development of their baby, particularly in the first trimester. Examples such as folate, a water-soluble nutrient, but in low levels prior to conception and in the first weeks of pregnancy can have catastrophic consequences on that baby's spinal development, leading to spina bifida, rubella, mild illness in the mother, fleeting rash, low level temperature, but consequences of the baby affecting vision, hearing and intellectual development. And now gestational diabetes, a modern problem having that impact on impaired glucose tolerance on the future child, the physical health of the mum impacting on the baby well understood.
But now we have emerging evidence on the psychosocial health of that mother and father, we'll talk about later impacting on that psychosocial health of the baby. The best study that we have is a cohort study from our own Western Australia called the Raine study. 2890 women followed up from their pregnancy in 89 and 90 and then what happened to those children, as monitored by a child behavior checklist. They documented during the pregnancy the kind of stressful events the events that can happen as part of life that happened to that mother. The timing, the type, and the number of stressful events were documented. They then linked that to the child behavior checklist and found that if that mother had suffered more than five stressful events in the pregnancy, then that child was manifesting abnormal results to a child behaviour checklist, later on in their childhood.
Now we know that pregnancy itself can have an impact on the psychosocial health of mums and dads. Anxiety and depression, we know that one in ten mothers antenatally and one in seven mothers postnatally, that's fifteen thousand women every year in NSW can suffer from depression. There's also an impact on dads. 1 in 20 during the pregnancy and 1 in 10 postnatally. That depression and anxiety can have an impact on their future relationship with that child and the development that can happen in attachment behaviors. We also know from overseas studies where there is actually a pre-existing mental illness in the mother, that the impact of that is going to be greater if the mother doesn't take the medication. So this is a study that linked the mother's depression to whether she took her antidepressants or not, compared with a group of women who didn't have depression. And you can see the most worrying result linked to a strengths and difficulties questionnaire done on that child at the age of seven, was for the mother who had depression and didn't take antidepressants. All of this, adding to this picture that we have, that the mental health, the psychosocial health of the mother is having an impact on the psychosocial health and development of that baby, and ultimately the child and adult.
And the third aspect of what we know is happening during that antenatal period is about that baby's lifelong disease and morbidity being set. What we now refer to as DOHAD - the developmental origins of health and disease. First considered as a hypothesis by Dr Barker, who linked low birth weight to the potential of early onset of coronary artery disease. And as you can see from this graph, there was a link between low birth weight and coronary artery disease. So what's happening as that baby grows in the womb is setting up for life. We now move on to the second aspect of what we're talking about today: the brain and the brain development. An image of the night sky for a concept of neurons in a baby's brain at birth, all disparate, not connected. Over a thousand, trillion are going to be connected over the next years as a result of that baby's experience, as a result of the nurturing and the care that that baby is going to have from important carers, loving attachment in those first years of life. If you see in our head circumference chart in every personal health record, just look at how steep that curve is in that first year, and years of life and imagine that that is being forged by brain connections. Brain connections that are occurring as a result of the stimulation between a loving primary attachment figure and that baby. Indeed, we have pet scans that have demonstrated, as you can see with that image of the brain with lots of darkness there, where there just isn't the brain architecture forged, where these babies in the Romanian orphanages suffered extreme neglect and there isn't the brain architecture, compared with the other pet scan image of that healthy, red, lit up brain. And that's what we're looking for in the brain development of children.
Indeed another aspect that we understand more now, is that we have critical window periods and if you have a look at that graph most of them are in the first two thousand days of life. So that is where that child is going to be needing that stimulation for vision, hearing communication, cognitive development, emotional development. And just look at how critical that window period is, how steep those graphs are and how they begin to wane after the first 2000 days of life. Indeed we know now from a UK study that a developmental assessment at just 22 months is an accurate predictor of that child's educational outcomes at 26 years. 22 months predicting 26 years.
And now we move on to childhood experience. I'm just going to talk about one study, a very pivotal study done by Vincent Valetti and linked with the CDC. Adult clinicians concerned about a group of patients that just didn't seem to get better compared with other groups of patients and probing in their history found that this group was related to ones who had experienced adverse childhood experiences in their early years and indeed this led to them developing what's known as an ACE score out of ten. That score is gained: three for the different types of abuse physical, sexual or emotional two for neglect - emotional or physical and then five for what's happening in the family home, such as domestic violence, substance abuse mental illness, parental separation or divorce, or incarceration. And tragically, if a child has a score of six or more, the prediction is that they will die 20 years earlier than a child who has a score of zero.
We know the mechanism is toxic stress, stress not buffered by supportive adult relationships and that leads to health risk behaviors, or not, even, without that we know that there is earlier onset of disease and ultimately earlier onset of death. We know that that affects the child when they are a child, that stressful environment will have an impact on their development and as you can see by the other graph it will also have an impact on their earlier onset of coronary artery disease, and indeed the six major killers are all determined and influenced by adverse childhood experiences and what have covert, what will that have as an impact for us looking into the future, will it be a negative or a positive force? This is something we need to monitor and look into very carefully.
So the exciting thing is that the evidence has given us an understanding of the mechanism of the importance of the first 2000 days. Another ABC we understand, the anatomy, the biology, the chemistry. We've got data linkage and epigenetic evidence and if we understand the mechanism we can understand the interventions and the most important intervention is a attachment. How are we going to ensure that every baby has that best positive attachment with a caregiving adult, in particular in those first 2000 days? It's supported by other mechanisms where we work on brain plasticity, chemistry and resilience. We get the community to support and look at epigenetics.
For the positive, so this has all come together in our First 2000 Days Framework and we have three objectives that we hope will make a big difference to the outcome of our children the first objective and this is probably one of the most important of the three and that is that everybody understands everybody has this health information of the importance of the first 2000 days because if parents and caregivers understand the importance then they're going to make choices that are informed choices about the importance.
Indeed tragically what we understand now is the general public doesn't understand the importance of the first 2000 days, or the importance of the role of adults in that child's life. Indeed it's the opposite. They think the child is in a bubble not influenced by what can happen around them by adults. Just imagine, if adults don't think that domestic violence or the circumstances that baby is growing up in is actually having an impact on that baby, which we know now to be true. The other, very concerning, misunderstanding is that the general public doesn't think that you can influence a child's cognitive or emotional development until they start to speak. Just think back to those graphs. Think of how much was happening before that child begins to speak. Think about the evidence that at 22 months you can predict educational outcomes at 26 years.
The earlier that we support babies, from conception to the age of five is critical. This is evidence that we now have about every week counting, to the pregnancy going to full term and so we're not talking about clinical reasons, where the baby needs to be delivered with the mum or the bub but we're talking about for no other than a social reason, people choose to have that baby delivered at one two or three weeks early, and if they do for every week that is earlier than full term, that child has a greater risk of learning disorders. Indeed in the last five weeks of pregnancy, a third of the weight of the brain is growing, so that's critical information that people need to understand.
The second objective is about the importance of us providing care for everyone. In our universal health system and probably none more important than developmental surveillance, because indeed we know now in NSW that one in five children are arriving at school developmentally vulnerable on one or more domain and one in ten on two or more domains and the why that's particularly important, is that we know because of linked data from the Australian Early Development Census to NAPLAN results, that those first two thousand days, the way that child arrives prepared for school is actually going to determine their NAPLAN results. So the support that that child needs is before they arrive at school, to be able to reach their maximum learning potential and we have learned the science. Act early, which is a developmental surveillance tool that we hope is widespread and used more broadly.
And then finally, our third objective which is we need to provide more for those who need more. Those families where they aren't able to keep their children and the children go into out-of-home care. Those families where there is domestic violence, where there is concerns even antenatally, we know that will have an impact on that baby. Those families where there is alcohol abuse during pregnancy. So tragically, we know that Fetal Alcohol Spectrum Disorder is the single largest cause of developmental disability in the western world. it is more significant than autism, than cerebral palsy, than down syndrome, than tourettes, all together. And this cause of brain damage, developmental disability is actually a hundred percent preventable, and yet one in two women will drink in pregnancy and one in four will continue to drink when they know they're pregnant.
So in conclusion, we've reviewed the evidence on this new ABC, the importance of antenatal care on brain development and childhood experience. Indeed we know now how important the first 2000 days of life are for life. We are now in a position to provide the best possible start to life for our children.