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Ernesto Polllu,4
of
Most investigators recognize causality in severe protein-calorie malnutrition, especially in nutritional marasmus, as being complex and multifactorial (1-3). Hegsted (4) points out that investigators accept different factors as significant and accord them different emphasis. Factors include inadequate quantity and quality of food, poverty, an unsatisfactory physical and psychosocial environment, and parents who are ignorant of appropriate child care. The major cause of protein-calorie malnutrition is generally placed in factors of the as a
data relevant to the issues raised above and to propose the hypothesis that behavior of the infant influences occurrence of nutritional
marasmus. Multiparity
malnourished of
Peru
later
A in or
physical,
environment.
biological,
Except
and
for
sociopsychological
noting anorexia
contributory
is not affected taken by is usually that
factor,
into of the
the
behavior
The infant of
of the
impression
host
left
poverty.
causality els child
Such
resembles
a
used Most
unilateral
to often explain the by for
explanation
of
sociopsychological child
of kwashiorkor, 88% were third or later born (7) (Table 1). In Colombia, 49% of 145 children with protein-calorie malnutrition were sixth or later born. By contrast, Table 2 shows that only 37% of 386 children who were fifth or earlier born had a similar condition (P < 0.05) (8).
Closely spaced pregnancies
of a family.
Of 55 cases
commonly behavior.
Other
ciation closely Jordan,
reports
between spaced 78%
demonstrate
preschool pregnancies of
a close
malnutrition the mother. of malnourished
assoand In
behavior
constitutional or temof the child (5, 6). the behavior of the child as
because marasmic of
of the
mothers
children
pregnancies
weaned
(9).
their
A
babies
significant
because
positive
of new
cor-
reports
that weaned
of of
are
spring history
are
commonly
women
Of
79
children
numbers of preschool chiland preschool malnutrition in the Colombian study cited. with four or more preschool of Nutrition and Food
the Department
Science, Massachusetts
behavior,
prior to the developIn turn, such condifood intake and therestatus. is to present
Journal
available
of Clinical
Institute of Technology, Cambridge, Massachusetts 02139. This publication is contribution No. 2000 from the Department of Nutrition and Food Science. by Public Health Service Contract No. NIH 7 1-2417 with the National Institutes of Child Health and Human Development, Bethesda, Maryland 20014. 4Associate Professor of Growth and Development, Department of Nutrition and Food Science. Nutrition 26: MARCH 1973, pp. 264-270. Printed in U.S.A.
The American
CAUSATION
OF
NUTRITIONAL
MARASMUS
265
siblings, 47.9% were malnourished, whereas 352 with three or less preschool siblings had a frequency of only 29% (8) (Table 2). In a study of undernutrition and mental development in Colorado (10), similar patterns occurred; e.g., 19 children admitted to the Denver General Hospital with generalized undernutrition were compared for selected social factors with matched controls of similar economic level. One differentiating social factor was the stress of one or two siblings less than 2 years old. These findings were corroborated in a study on the effect of socioeconomic and cultural influences on child growth in the village of Lawrence Tavem in Jamaica (1 1).
TABLE
Family
1
size and birth order of patients
kwashiorkor
and nutritional
marasmus
Type
with in Perua
of malnutrition
51 3.9 2-10 1 5 15 6 3 4 28
b
22 5.0 2-12
Patients
order
of birthb
(3) (15) (44) (18) (9) (12) (82) 1 (5) 6 (27) 6 (27)
First born Second Third Fourth Fifth Sixth or later Last born
a
9 (41) 22 (100)
Low
birthweight From
not
(7).
Two
atypical
cases
oimarasmus in parentheses
There are fewer than a handful of studies on birthweights of severely malnourished children. That lack is wholly understandable, given the generally low education of mothers,
the unreliability of retrospective data, and
are are
included percentages.
(see text).
Numbers
the
the inadequacy of clinical records in hospitals servicing rural or low income areas (12). Moreover, prospective studies in which the case histories of low birthweight children are followed until they become severely malnourished are rare because of obvious moral implications. Some published data suggest that children who become severely malnourished often had low weights at birth. For example, in the Colorado study (10), 10 of the 19 cases with generalized undernutrition had birthweights of 2,500 g or less. A sample
of malnourished weights above
TABLE 2 Association of protein-calorie preschool children with birth preschool children in family
of
I
Demographic factor Population in category
reported by Monckeberg (13). His sample of 14 hospitalized malnourished children had a range in birthweight from 2.9 to 3.8 kg (in = 3.4). Despite reports to the contrary, it is indeed
probable that the incidence of prematurity
children 2,500 g
all is
with
birth-
Birth rank 5th or lower 6th or higher No. of preschool children in family 3 or less 4 or more
a
773 295
286 145
37.0 49.2
<0.05 7.52
352
39.0
79
47.9
<0.05 4.23
Adapted of
from
regardless maturity
rates being
economic positively
among
level,
rates with
of parity,
prethe
correlate
greatest
grandmultiparous
women
spaced
or low birthweight among nutritionally marasmic children is greater than that for the general population. This inference is supported by information of adverse effects of high parity and short spacing between pregnancies. A considerable amount of research data shows an increased reproductive risk, most marked in low income groups (14), as a function of parity. Birch and Gussow (14) show from a review of relevant studies that,
closely that children born within 1 year of a previous full-term pregnancy have lower birthweights than those born after 2 to 5 years (16). Rosa and Turshen (16) quote an unpublished study in Uganda in which infants with birthweights under 2,500 g were born an average of 18 months after the mothers last pregnancy. By contrast, for infants weighing more than 2,500 g, the average interval was 30 months.
(15).
pregnancies, there is evidence
In
connection
with
266
owrr
nutrition is greater in developing countries or
Accordingly, there is justification for inferring that a considerable proportion of severely malnourished children are premature or have lower birthweights than the
in low income
areas
where
birthweights
aver-
population
TABLE
Mean status
average.
3
The
incidence
of mal-
age less than in developed countries or in high income areas (17, 1 8) (Tables 3, 4). Low birthweight in developing countries and
in low income
retarded
to socioeconomic and Indonesia)
Mean birthweights,
areas
intrauterine
from from
Place
Population
Subjects
status
Madras South
Bombay
Indian
2,985 2,736
3,182 2,810 3,247 2,945 2,796 2,578 2,851 2,656
in fetal nutrition (16, 19). If average birthweights of severely malnourished children fall on the negative side of distributions of population birthweights, they are likely to be significantly below the WHO cutoff point (2,500 g) for prematurity. disturbances
India
Indian Indian
Early
weaning
A few reports
nutritional
also
show
for
early
weaning
com-
in to
that
marasmus:
example,
paring
kwashiorkor
Marasmus
his
experience
in Jordan,
with
McLaren
marasmus
says
has
more
complex
basic
Calcutta
Indian
Congo
Bantu
etiology with a monotonously tern of early weaning (9). study of 22 cases of typical
3,026
2,965 2,850 2,635 3,188
average duration of only 2.0 months of exclusive breast feeding was recorded; in kwashiorkor it was 7.8 months. Malnutrition appears to develop slowly as breast feeding ends, and the diet thereafter
ments
Ghana
(Ac-
Pygmies African
Prosperous
fails
of
cra) General
lation
popu-
2,879
3,022
to meet the nutritional the infant. There is interdisciplinary surveys of early weaning (20). effects
Well-to-do Poor
2,816
Mean
birthweig
bts,
kg
immature with
then
children spaced
hypoth-
Congo
Nigeria
Nigeria
Nyasaland, rural South Africa (Durban) Southern Rhodesia (Salisbury) Uganda (Kampala)
a
(2.92)
(2.86) (2.89)
(3.90) (3.01) (2.99)
(3.07) (2.86)
(2.95)
6 ib, 8 oz
b
Adapted
from
(19).
Now
known
as
Malawi.
born to mothers who had experienced a large number of closely spaced pregnancies would be lethargic. Specifically, they were interested in whether newborns from large, densely concentrated families were inefficient in obtalning nourishment as measured by suck rate and number of sucks, would cry little, and with low intensity even when uncomfortable and hungry, and would be slow to respond to a stimulus such as the removal of a nipple on which they were sucking.
CAUSATION
OF
NUTRITIONAL
MARASMUS
267
Waidrop score as
2)
(FSD). average span in months between births, and 3) months to the next older sibling. They observed the behavior of 74 infants born to multiparous women, and only children with weights over 2,500 g were included in the
sample.
and Bell developed a composite family size and density index It included: 1) number of children, a
eating
neonatal
behavior group
authors
with
in this
above average
latter of
investigation
birthweights.
was
that
The
existence
a positive
correlation
The sucking
with posi-
density of food
positive later,
index intake.
proved a Furthermore,
nificant
2.5
years
against a nursery school rating of contact with a female teacher (r = + 0.36; P <
0.01); the correlation exhibited score, with ability by contrast, the number to defend (r = -0.35; had a negative of times a child himself against P < 0.01).
Barnett
and
amount
no relationof formula
consumed
by infants
regardless
of whether
the infant was fed by a nurse or mother, although such variables as age did evidence an effect. Note, however, that Thoman et al. used only parity as a variable, whereas Waldrop and Bell (21) employed a composite score including months of age difference between the children studied and the next older sibling and average span between births of all the children of a family as well as parity. Moreover, Waldrop and Bell assessed the effects of different numbers of pregnancies, whereas Thoman et al. assessed multiparity as a global category in which most mothers were of second and third parity. Two recently published studies yielded positive associations between birthweight and food intake. In a sample of 210 babies, the heavier babies had a larger mean daily intake in calories and ounces than lighter infants, a relationship apparently mediated by differences in sucking behavior (23). A similar pattern was established in a study on the
between the effectiveness of the suck and weight at birth among 40 infants with birthweights ranging from 1,700 to 2,500 g endorses the clinically well-known fact that the suck-swallow pattern of premature infants is less adequate than for infants of normal weight. An extreme illustration of this inadequacy is reported for seven infants of 1,800 to 1,890 g (32 to 34 weeks gestation); when offered the nipple for the first 3 to 5 days, they mouthed it with only slight sucking attempts. The first true sucking appeared 3 to 10 days after initiation of feeding (10 to 26 days of age) (25). In another study on the sucking capability of 49 premature infants, birthweight and rate of water intake during the first 3 days of life were found to be positively and significantly correlated. Birthweights ranged from 1,350 to 2,450 g; 32 infants weighed 2,000 g or more. A similar relationship existed between water intake during the first 3 days and formula ingested from the 4th to the 6th day of life. The 49 premature infants, with a mean birthweight of 2,109 g, had a mean sucking rate of 0.2 to 0.3 cm3/sec within the first 3 days of formula feeding. By contrast, the mean sucking rate of 32 full-term controls, with a mean birthweight of 3,231 g,
was
0.6
cm3/sec.
No
association
existed
be-
tween
birthweight
and
sucking
efficiency
among the full-term controls (26). Nutritionally marasmic children born of grandmultiparous women with closely spaced
pregnancies and with low birthweights would presumably be doubly handicapped. They are probably unable to ingest maternal milk in amounts sufficient for usual development during at least the 1st month of life due to lethargy or immature sucking. A study on weight gain of infants during the 1st month of life was a function of average quantity of formula ingested per day (27). Bell has brought out that parent and child together constitute a social system wherein the response of each is a stimulus to the other. He postulates that parents have a
268
PoLzm
repertoire of actions aimed at accomplishing different socializing objectives in the child, and that one of the activating elements in the repertoire is stimulation from the object of acculturation. Such usual characteristics of infants and children as helplessness evoke responses. Bell differentiates two types of
3 weeks and again at 3 months quency of the mothers contact fant. A causal sequence in relationships apparently exists instigates maternal intervention
with
parental control repertoire. One, an upper limit control behavior, induces and redirects behavior of the child which exceeds parental standards of intensity, frequency, and competence for the childs age; the other, lower
child bestandards. Parent control behavior is, in a sense, homeostatic relative to child behavior. To illustrate, Bell (5, 6) states that the average limit havior control that behavior, is below stimulates parental
other study on mother-neonate interaction gave evidence that a mothers engagement in feeding her young depended upon the level of infant activity. The mother would not rouse an infant for feeding if the child was
asleep relation Finally, a highly significant corbeen reported between infants during breast feeding and the number (31). has
intake of weeks
the mothers
breast
fed their
children
Downloaded from ajcn.nutrition.org by guest on November 22, 2013
may In a
parent
would
show
an increase
in upper
limit
(32). In severe infant malnutrition, extend past an effect on child study of 40 mother-neonate
parity behavior.
control behavior in response to excessive crying by an infant, or in response to impulsive, hyperactive, or overly competent or assertive behavior by the young child. In keeping with the above, it can be assumed that lethargic, listless behavior in an infant could evoke lower limit control
behavior in the parents to enhance the re-
pairs including primiparous women talked more to their infants and provided more general stimulation. Primiparous mothers who talked frequently to their young also fed them for longer periods of time (33). The investigations just cited suggest that 20 multiparous women,
attention to the child varies with parity. That being true, late-born children conceivably receive less attention than needed, the problem being accentuated if late-born children are lethargic and possess a limited behavioral repertoire that fails to attract maternal attention. Both conditions could then interfere with meeting nutritional needs,
sponsivity of the child, thus facilitating the developmental process. Different types of parental response might, by contrast, reinforce lethargic behavior, thereby hindering
socialization and, possibly, physical growth. Early weaning of marasmic children might well be a maternal response to ineffectual sucking and lethargy of the infant. Also,
declining breast milk output from decreased
through earlier
nutritional Implications
limiting weaning,
marasmus.
feeding resulting
and in
pituitary
prolactin
might
be
due
to
inadeExcept for attention to greater morbidity and anorexia, the role of the host has had far less consideration than environment in analysis of causality of severe malnutrition. Evidence has been introduced that selective be-
quate nipple stimulation. Early weaning fails to enhance responsivity of the child and creates instead an organic imbalance if the substitute diet lacks nutritional requirements
in protein and calories. Studies on infant state and havior support an assumption
can regulate maternal response
timing of weaning. State, a popular term in infant behavioral research, defines activity level and degree of alertness in the infant (28, 29). In a study on influence of infants sex, age, and state upon mother-infant interaction, the frequency of cries in female infants correlated positively during the
first
to nutritional
immature
sucking
response
hinder
milk intake and secretion; similarly, both factors might adversely affect the ability of the child to stimulate the attention of a
mother children.
heavly
burdened
by
care
of
other
CAUSATION
OF
NUTRITIONAL
MARASMUS
269
Ineffective sucking and lethargic behavior are probably hardly necessary nor sufficient conditions to produce malnutrition; both characteristics, however, place the child at the risk of malnutrition. Physical and sociopsychological environmental conditions will probably dictate a developmental course to
tent protected even in a severely adverse environment. The proposed hypothesis that behavior of the infant influences the frequency of severe malnutrition requires testing. If valid, the implications are important, substantiating the need for education in child care within
health
and
nutrition
programs
in low income
malnutrition in Candelaria, Colombia. I. Preyalence: social and demographic causal factors. J. Trop. Pediat. 15: 76, 1969. 9. MCLAREN, D. S. A fresh look at proteincalorie malnutrition. Lancet 2: 485, 1966. 10. CHASE, H. P., AND H. P. MARTIN. Undernutrition and child development. New Engl. J. Med. 282: 933, 1970. 1 1. DESAI, P., K. L. STANDARD AND W. E. MIALL. Socioeconomic cultural influences on child growth in rural Jamaica. I. Biosocial Sci. 2: 133, 1970. 12. PoLLIrr, E., AND H. RICCIuTI. Biological and social correlates of stature among children in the slums of Lima, Peru. Am. I. Orthopsychiat. 39: 735, 1969. 13. M#{212}NCKEBERG, F. Effect of early marasmic malnutrition on subsequent physical and psychological development. In: Malnutrition, Learning, and Behavior, edited by N. S. Scrimshaw and J. E. Gordon. Cambridge: MIT
areas or developing countries. Specifically, public health education in feeding practices requires incorporation of measures to compensate for ineffective sucking, as well as the means to stimulate the sucking response of the lethargic child. Furthermore, another reason to integrate family planning within health programs is that the large family
Press,
14.
BIRCH,
1968, p. 271.
15.
H. G., AND J. D. Gussow. Disadvantaged Children. Health, Nutrition, and School Failure. New York: Harcourt, Brace and Jovanovich, 1970, p. 81. DONNELLY, J. F., C. E. FLOWERS, R. N. CREADISK, H. B. WELLS, B. 0. GUENBERG AND
K. B.
SURLES.
Maternal,
fetal,
and environmen-
of the child
as well
as his
critical
E. Gordon
comments
are gratefully
and
suggestions
acknowledged.
of Dr.
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