ABSTRACT

It is thought that supporting the early childhood period, which is of critical importance in terms of cognitive, social, emotional and physical development in children, with the components of the developmental care scope will increase the peace and welfare levels of future generations. In addition to the applications carried out in this context in our country, there is also a need for applications that we need to add to our health practice. The purpose of the review is to talk about the scope of nurturing care and nurturing care practices in our country in the light of current information and to offer suggestions to further develop the scope.

INTRODUCTION

Early childhood, which covers children’s first eight years of life, constitutes the cornerstones of cognitive, social, emotional and physical development. In this critical period, the development of children, poverty, nutrition insecurity, gender inequality, violence, environmental harmful substances and the mental health of parents or caregivers are influenced by many factors¹. Starting from the pregnancy process, these risk factors are known to have significant effects on early childhood development. Studies on a global scale reveal that at least 250 million children under the age of 5 years are in danger of not reaching the development potential². In order to address this situation, a model has been developed by the WHO, UNICEF and other common organizations to ensure that children can healthly exist, grow and realize all their potential in life³. This scope was introduced at the 71^st World Health Council meeting in Geneva in May 2018⁴. In this study, the concept of nurturing care and its components were handled, nurturing care practices in Türkiye were examined, and it was aimed to provide suggestions for the development of these applications.

The Scope of Nurturing Care

Early childhood plays a fundamental role in terms of life-long health, welfare, learning skills and productivity of the individual. In this period, in order to support the healthy growth and development of children, parents or caregivers should be supported within the framework of nurturing care². It consists of five basic components: health, adequate nutrition, sensitive care, early learning opportunities and safety³. In this context, starting from the pregnancy period, a child -oriented and family- centered approach should be adopted in the first three years of life⁵. In order to meet the developmental needs of children, UNICEF and other stakeholders have identified the nurturing care indicators. These indicators have been implemented in 197 countries since 2018 in order to follow up the development data of early childhood in the countries and evaluated through 42 indicators. These indicators within the scope of nurturing care include: demography (country population, population of children under the age of five, the number of annual births, the rate of death under the age of five), the factors that threaten child development (child poverty, dwarf ratio, low birth weight, preterm births, mother mortality, adolescent pregnancy rate, violence and neglect) and rate of children at risk (risk distributions according to gender and locations). Furthermore, the economic cost of the growth deficit of children at risk for development, early childhood development index and their functional problems are among the criteria of evaluation. The indicators of sub-components such as health, nutrition, early learning, sensitive care and safety are monitored at national and global levels⁶.

Health

Regular monitoring of children’s physical and emotional health, response to their daily needs with love and appropriately, protection from home and environmental hazards are among the priority responsibilities of parents or caregivers. With hygiene applications, minimizing the risk of infection, utilizing preventive health services and timely treatment of children is of great importance. The nurturing care approach aims to support the health and welfare of not only children, but also parents or caregivers³.

Adequate Nutrition

Nutrition of the pregnant mother during pregnancy has a critical role not only for its own health, but also for the growth and nutrition of the developing baby. For the first six months from birth, only breastfeeding should be supported with skin-to-skin contact. After the sixth month, in addition to breast milk, a nutrition process is required with balanced and various complementary foods suitable for the age of the child. Adequate nutrition, which is one of the main components of nurturing care, is directly related to the nutritional safety of both the child and the family³.

Sensitive Care

Sensitive care involves careful observation of children’s gestures, sounds, movements and other communication signals and responding appropriately to them. This understanding makes it easier to recognize and meet the basic needs of children. This approach, which also includes sensitive nutrition, supports children’s growing in healthy way³.

Early Learning Opportunities

In a loving and safe family environment, it is very important for children to reach learning opportunities with daily life activities and interpersonal interactions. Such guidance and mutual interactions are necessary for children to develop social skills and understand their relationship with others. Early learning opportunities are one of the main components that support children’s cognitive and social development³.

Safety

Children are quite vulnerable to physical injuries, environmental dangers and emotional stress. Safety, another important element of nurturing care, includes physical and emotional protection mechanisms that will make children feel safe. This approach is critical to support children’s healthy growth and development³.

Nurturing Care Practices in Türkiye

In Türkiye, the “Early Childhood Development Policies Project” has been implemented in cooperation with the Association of Child Development and Educators and UNICEF within the scope of policies for early childhood development. Early Childhood Development Platform was established as an output of this project and various non-governmental organizations operating in order to support early childhood development were brought together⁵. 2023 data on nurturing care indicators in Türkiye are summarized as follows:

Türkiye’s population is 85,341,241 and the annual number of births is 1,236,900. The number of children under the age of five was calculated as 6,421,178, which corresponds to 8% of the total population. The death rate under the age of five is 9 per thousand. The mother mortality rate was recorded as 17 at every 100,000 births. Low birth weight ratio was reported as 13%, preterm birth rate as 12%, the rate of dwarfness under the age of five as 6%. While data on child poverty are unavailable, the rate of neglect related to violence and disciplinary methods is 6%. The proportion of small children with developmental risk was recorded as 18% in 2005, 15% in 2010 and 4% in 2015 and this rate has decreased over the years. There are not enough data in the risks categories by settlement and gender. Early childhood growth deficit is estimated to have a 48% effect of the individual’s annual income loss in adulthood. However, there is not enough information about children with functional problems. On the other hand, 74% of children of 36-59 months were evaluated as developmentally normal⁷.

The proportion of children applying to health institutions on suspicion of pneumonia in Türkiye is 45%. The proportion of four or more antenatal care areas during pregnancy is 90% and the rate of those who benefit from postnatal care services is 79%. There are no data on pregnant women receiving Human Immunodeficiency Virus treatment (health). While 71% of infants begin to be breastfed immediately after birth, the rate of those fed only with breast milk for the first six months is 41%. There are no data about minimum acceptable diet (nutrition). While 65% of children are supported by early learning opportunities at home, the rate of those who have toys is 76% and the rate of those who have books is 29%. There is no information about the rate of attendance in preschool education (early learning opportunities). The birth recording rate is 98%, access to basic drinking water is 97%, and the basic sanitation rate is over 99%. There are no data on positive disciplinary applications (safety). There are not enough data on the quality of parental support, mental health, community information and child day care services (sensitive care)⁷. In Türkiye, while the duration of paid maternity leave varies between 14 and 18 weeks, paternity leave is shorter. The law for the marketing of breast milk substitutes is partially applied. Although there is a national minimum wage, social protection policies for children and family are limited. International Agreements: Türkiye has been party to the Convention on the Rights of the Child, Convention on the Rights of Persons with Disabilities, and Convention on Protection of Children and Cooperation in Respect of Intercountry Adoption⁷.

Health

In order for pregnant women in Türkiye to have a healthy pregnancy and to provide more conscious care for their newborns, the Ministry of Health launched the “Pregnancy Schools” practice in public and private hospitals with the Circular (2018/23) published on October 2, 2018. The four-week training in these schools is provided by expert health personnel. The training covers topics such as pregnancy physiology, nutrition during pregnancy, preparation for birth, types of birth, pregnancy exercises, breathing awareness, methods of coping with pain during pregnancy, newborn care, the importance of breast milk, breastfeeding techniques, postpartum period and family planning⁸. A study has shown that pregnancy schools are effective and that the cesarean section rates are lower than in control groups regardless of the education level, income level or employment status of the participating women⁹. In this context, pregnancy schools are considered an important tool for reaching the WHO prenatal care and education standards and the recommended cesarean section rates. In line with the “Prenatal and Postnatal Management Guide” published by the Ministry of Health, it is aimed for pregnant women to be monitored at least four times in a qualified manner and for postnatal care to be provided both in the hospital and at home. In this process, the frequency of postnatal monitoring includes three home visits after the hospital. In addition, deliveries occur in hospitals, and, if necessary, stabilized patients are referred to higher-level facilities¹⁰. Before and during pregnancy, women are screened in family health centers for problems such as maternal infections, thyroid diseases, gestational diabetes, preeclampsia, eclampsia, anemia, and asymptomatic bacteriuria. In addition, women are given free diphtheria-tetanus vaccine and iron, vitamin D, and folic acid supplements are provided. However, it is recommended that the diphtheria, tetanus and pertussis (Tdab) vaccine should also be offered free of charge to pregnant women. Given that pertussis infection can cause serious respiratory distress in young infants, the Tdab vaccine provides passive immunity to both mother and baby when administered between the 27^th and 36^th weeks of pregnancy¹¹. Regular monitoring of children’s growth and development from birth is of great importance in terms of taking preventive measures. In this context, the Ministry of Health’s infant, child and adolescent monitoring guide provides detailed screening, examination and vaccinations specific to each age group. This guide aims to protect children’s health and to raise awareness and empower families on this issue¹². Screening examinations provide an opportunity for early diagnosis of physical, emotional, developmental and behavioral problems in children. Such interventions can reduce the burden of disease that is carried into adulthood¹³. In Türkiye, the “Regulation on Special Needs Assessment for Children” published in 2019 for children with special needs adopted a non-stigmatizing and holistic approach. The Special Needs Report for Children aims to ensure that at-risk infants and children with developmental delays benefit from early intervention services¹⁴.

Nutrition

Starting from pre-pregnancy, during pregnancy and breastfeeding, the mother’s nutritional habits have a significant impact not only on the mother’s health but also on the baby’s development. In recent years, it has been emphasized that these processes determine the child’s long-term predisposition to health problems such as obesity, diabetes and cardiovascular disease, and that they reveal an approach called “early metabolic programming of long-term health”¹⁵. Therefore, it is important to correctly determine the nutritional needs of women in primary health care services and to evaluate these needs at each follow-up. It is also recommended that micronutrient deficiencies be identified and the necessary support be provided.

WHO recommends that babies be exclusively breastfed for the first six months of their lives and that breastfeeding should continue until at least two years of age¹⁶. Initiating breastfeeding, especially within the first half hour after birth, increases the mother’s confidence in her milk and strengthens the reflexes that support milk production and secretion. During this period, mother and baby staying together is critical for the sustainability of breastfeeding¹⁷. In order to increase breastfeeding rates in Türkiye, the “Breastfeeding Consultancy” and “Baby-Friendly Hospitals” programs were launched in 1991. In addition to these programs, practices such as “Mother Support Groups”, “Mother to Mother Support Groups”, “Baby-Friendly Province”, “Golden Baby-Friendly Provinces”, “Baby-Friendly Family Medicine” and “Baby-Friendly Workplace” were developed. With the increasing importance given to kangaroo care in neonatal intensive care units, “Baby-Friendly Neonatal Intensive Care Centers” were launched. It is possible to further increase breastfeeding rates with policies such as providing 1.5 hours of daily breastfeeding leave for working mothers until the child is one year old, and extending the paid leave period after birth until the child is two years old. In addition, the regulations of the “International Code of Marketing of Breast-milk Substitutes” should be fully implemented and formula advertisements should be monitored¹⁸. Complementary feeding should be started from the sixth month onwards, as breast milk does not meet all the nutritional needs of the baby. During this process, it is important to choose foods that are appropriate for the baby’s age, prepare them safely and store them appropriately. Complementary foods should be introduced in gradual transitions such as puree, lumpy and solid consistencies. In addition, factors such as meal frequency, energy density, vitamin-mineral support and continuing breastfeeding during illness should be taken into consideration¹⁹. In a study evaluating the complementary feeding practices of babies aged 6-12 months, it was concluded that in order to prevent deficiencies in infant feeding, it should be done individually, practically, and in a way that will provide solutions to mothers’ questions and problems, taking into account their education levels. The “Baby-Friendly Complementary Feeding” practice in Türkiye should be widespread, especially in primary health care services²⁰.

In order to prevent obesity, the “Türkiye Healthy Nutrition and Active Life Program (2010-2014)” was launched in cooperation with the Ministry of Health and other sectors and this program was updated between 2018-2023 as a result of the WHO evaluation. The program includes various strategies aiming at providing children with healthy eating habits and encouraging physical activity²¹. In addition, it is recommended that hyperlipidemia screenings be applied to all children in the risk group starting from the age of two¹².

Early Learning

In the early years of life, the inadequacy of environmental stimuli and the limited learning opportunities can lead to disruptions in both emotional and physical development of the child. These deficiencies can cause development delays in language, cognitive, motor, social and emotional fields in addition to forming the basis of behavioral problems²².

Regular book reading activities with babies have positive effects on language development, social-emotional skills, early literacy skills, parent-child communication, and the quality of the home environment. Therefore, during child health monitoring, early and regular book reading recommendations should be made to families²³.

One of the most effective methods for children to learn is to use tools that support sensory perception. Especially age-appropriate, well-designed and accessible toys contribute significantly to the development process of children. Cheap but functional toys can provide more benefits than expensive but inadequately functional ones²⁴. It is very important for those who care for the child to communicate with the child by playing and to turn playtimes into education and fun. Play supports the child in gaining the skills he/she will need in daily life and in developing basic rules and behavioral habits. It can also help him/her cope with stress²⁵. As the famous play therapist Garry Landreth put it, “play is the child’s language, and toys are his/her words”.²⁶

Toy libraries, which all children can benefit from regardless of socioeconomic inequalities, are resource centers that provide support, counseling, information about play, educational materials, and toys to young children and their families. These libraries operate on a toy lending system and offer materials appropriate to the development of children²⁷. Expanding the existing toy libraries in Türkiye will be an important step in creating early learning opportunities especially for disadvantaged children and strengthening developmental care services^{28, 29}.

The preschool period is a critical period in terms of the speed of brain development and the density of synaptic connections. During this period, the brain is most sensitive to environmental factors. The child’s development should be supported by rich cognitive stimuli, quality language experiences and positive social-emotional interactions. A quality preschool education develops the child’s sense of independence and creates a positive attitude towards learning. According to the regulations of the Ministry of National Education in Türkiye, the care and education of children aged 0-36 months is provided in kindergarten, while the education of children aged 36-72 months is provided in preschool³⁰. However, in Türkiye, children from high-income families can generally attend preschool education, while children from lower-income families, those with less educated mothers and those with many siblings directly start primary school³¹. Public policies should be developed to prevent such inequalities and ensure that disadvantaged children have equal access to educational opportunities with their peers.

Safety

Every child born in Türkiye must be reported to the birth registration office within thirty days from the date of birth. Birth notification is made with an official document. Children born in marriage are registered in the household where their father is officially registered with the father’s surname, while illegitimate child is registered with the mother’s maiden surname. When paternity is determined by recognition or court decision, the child is registered with the father’s surname³². Worldwide, unsafe drinking water, poor hygiene, air pollution, infectious diseases such as diarrhea, and consumption of contaminated food are among the traditional environmental threats that negatively affect children’s health. Modern risks such as industrialization, unplanned urbanization, and the accumulation of toxic chemicals in the environment, especially in low- and middle-income countries, further increase these threats³³. In this context, all children should have access to a home and school environment where they can breathe clean air, consume safe water and food, and have hygienic practices. In addition, safe family and play areas should be established in both urban and rural areas³.

Extraordinary situations, such as natural disasters, wars, environmental pollution or technological accidents require special measures for the care of children. In such cases, the lists of children remaining orphaned should be issued and notified to the relevant units. Safety measures can be increased by attaching arm tapes containing identity information to children. In addition, families should be informed about child safety in these cases³⁴.

Child maltreatment can take the form of physical, sexual and psychological violence, neglect or abuse. In most cases, such treatment is perpetrated by parents, caregivers or authority figures and occurs in the home, school or care setting. Maltreatment can have long-term negative effects on children’s mental and physical health, social life and educational performance³⁴. During child health monitoring, the child and family should be assessed for maltreatment.

In some cases, children may become in need of protection and care due to reasons such as death, illness, divorce or abandonment. In Türkiye, the “Social Services Law” dated 24 May 1983 and numbered 2828 provides institutional care, foster family and adoption services for children in need of protection³⁵.

Sensitive Care

Practices such as skin-to-skin contact between mother and baby immediately after birth and kangaroo care for low-birth-weight babies are an important part of sensitive care³. A systematic review has shown that skin-to-skin contact initiated early in newborns accelerates the breastfeeding process, reduces the frequency of hypothermia, and facilitates the baby’s adaptation to the outside world. In addition, positive effects on the mother’s health have been observed, such as shortening the third stage of labor, reducing the risk of postpartum hemorrhage and reducing pain perception. This practice strengthens the bond between mother and baby and also reduces rates of maternal stress, anxiety and depression³⁶.

Responsive feeding refers to a feeding style in which the parent or caregiver is sensitive to the needs of the child. While providing responsive feeding within the framework of nurturing care, the baby should be expected to stop breastfeeding himself/herself, and feeding habits should be combined with reading books from the sixth month onwards. In addition, it is important to encourage young children to feed themselves and to pay attention to hunger and satiety signals. It should not be forgotten that meal times are an opportunity for both learning and sharing love. Making eye contact with the child during this process can strengthen emotional bonds³⁷.

Screen time refers to the time spent on devices such as television, computers, smartphones or tablets. The WHO and the Canadian Paediatric Association do not recommend screen exposure for children under the age of two, while the American Academy of Paediatrics sets this limit at 18 months. For older children, it has been stated that screen time should be limited and age-appropriate^{38, 39}. Excessive screen use can lead to problems such as musculoskeletal disorders, eating disorders, vision problems, sleep disorders, anxiety and depression in children. At the same time, negative effects such as attention deficit, hyperactivity and developmental delays are also observed⁴⁰.

Even background screen exposure can have negative effects on children’s language and cognitive development. This can lead to a decline in executive function skills⁴¹. Technoference, where technological devices interrupt communication between parent and child, also has negative effects on parenting processes⁴². In one study, mothers of children under the age of three reported that technological devices negatively affected their interactions with their children during play, reading, and mealtimes⁴³.

In order to reduce screen time, parents’ awareness of the negative effects of screen exposure needs to be increased. In addition, activities such as reading books and playing games should be encouraged with family-based approaches. These interventions provide successful results⁴⁴. Healthcare professionals should counsel families about screen exposure and technoference during child health monitoring.