Joaquin Cravioto

The Ecology of Infant Weight Gain in a Pre-industrial Society

Evidence deriving from several preindustrial societies indicates that weight gains made by children during the first three months of life are generally a t or above the average for infants in advanced European or American countries [l , 6, 8, 10, 11, 13, 151. Thereafter, a deceleration in weight gain and in overall growth occurs and is accompanied by severalfold increments in mortality [7, 121. The precise causes for this growth pattern are only partially understood and a more complete understanding awaits detailed ecologically oriented longitudinal studies of growth in representative com-

The Plasma Amino Acids in Malnutrition: Preliminary Observations

It is generally appreciated that malnutrition is the worlds foremost paediatric problem. Directly or indirectly it makes the major contribution to child mortality. Nevertheless, it remains an entity which is not well defined, or, more accurately, a combination of entities only some of which are well defined. We recognize the effects of certain specific food factors, the accessory food factors or vitamins, and we have some knowledge of changes brought about by deficits of the inorganic components of diet. The effects of caloric deficits, of protein deficits and of possible deficits of specific amino acids have, however, been difficult to separate. Protein and caloric deficits are commonly associated and the existence of syndromes of specific amino acid deficiency has not been definitely established although there is some evidence that they exist. It appears that the more exact definition of this area of deficiency will depend on chemical studies. We already know that plasma protein levels fall in protein deficiency, particularly the albumin fraction, and that blood urea is also reduced. We know that certain protein enzymes in the blood and the liver (Waterlow and Patrick, 1954; Burch, Arroyave, Schwartz, Padilla, Behar, Viteri and Scrimshaw, 1957) are diminished. It has seemed to us that observations on the free amino acids of the plasma might be of help in delineating specific entities within this area. The free amino acid level of the plasma might prove to be a more significant index of protein adequacy than other criteria that have been applied and the plasma free amino acid pattern, even if it could not be correlated with symptoms of specific amino acid deficiency, might yet be of considerable value in pointing to limiting amino acids and thus providing a sounder basis for dietary

PREVENTION AND TREATMENT OF CHRONIC SEVERE INFANTILE MALNUTRITION (KWASHIORKOR)

Variously known as Shibi Gachaki (Japan), Mehlnahrschaden (Germany), Kwashiorkor (Ghana), Sindrome Pluricarencial Infantil (Central America), and Protein Malnutrition (World Health Organization),’ chronic severe malnutrition is the inheritance of children living chiefly in technically underdeveloped countries. A number of factors-social, economic, sanitary, and educational-contribute to its high incidence. The cumulative effect of the negative action of each of these factors bears on millions of individuals throughout the world, and the prevention and treatment of the disease have thus become a world responsibility. Judged at the individual level, this process is the result of the interaction of a poor diet eaten in amounts that fall well below the minimal requirements. A brief description of the clinical record of a severely malnourished child may be helpful in trying to support some of our ideas in regard to prevention and treatment. The mother’s diet during pregnancy is in no way improved over her usual one. For the first 3 or 4 months, breast feeding is more or less adequate, as judged by the weight and height increments of the infant. Thereafter, although the average contents of protein and fat are not too different whether the milk comes from a malnourished or a normal mother, the quantity of milk diminishes in the former?, Even though it is true that children continue to suck a t the breast until they are 18 to 36 months old, studies by Platts have shown that, a t least in Gambia, the average amount obtained is only about one ounce per hour, so that “breast starvation”6 would be a better term for this than breast feeding. Weaning is instituted abruptly, generally because of a new pregnancy. The child is then fed gruels made with staples such as corn, rice, or millet, and sweetened with cane sugar. The baby is soon affected with bouts of diarrhea, primarily attributed to poor sanitary conditions. These attacks gradually increase in severity; contaminated food is the vehicle for these infections. During the attacks of diarrhea, the dietary intake becomes even more deficient since, as a rule, only corn-meal porridge or rice in water, with added salt or cane sugar, is given to the child. The poor sanitary conditions, which have persisted for generations, are partially responsible for the family’s fear of giving other foodstuffs, such as milk, in many communities. Diet surveys conducted in Mexico, Jamaica, Central America, Chile, Ceylon, and several parts of Africa have shown that the diets consumed by children * The work reported in this paper was supported, in part, by Mead Johnson & Company, Evansville, Ind. A typical dietary history reads as follows:

Nutrition, Mental Development and Learning

In recent years there has been an increasing concern both with the health of peoples and with the requirements of national development and public policy. This has led to the consideration of nutritional inadequacy as an important factor in the life of an individual from the time of gestation to the time of his acceptance of full responsibility as a socially functioning adult. This concern has not been limited to the developing countries. Industrial-advanced nations have also had to take nutrition into account in order to understand better both the health and educational performances of the marginal and/or minority segments of their populations. From a historical viewpoint, perhaps the greatest impetus to the study of the relation of nutrition to health and to human development was given by Orr (1936) who, in his classical Food, Health and Income, analyzed the relationships among nutrition, development, and health performance in the population of a technological-advanced country. Leitch (1959) summarized these relationships by stating that “whether the picture is of the broad differences between rich productive countries and the underdeveloped regions, or between social classes in this or in any other country, there is always a gradient with health in quantity and quality of diet associated with parallel gradients in rate of growth and adult stature, physical performance-mental ability and resistance to disease.”

Malnutrition and Kwashiorkor

1. Taking into account that only through the etiologic and pathogenic knowledge of a disease it is possible to attempt its correct interpretation, the authors have considered necessary to do a comparative study between Malnutrition and Kwashiorkor, as seen respectively in Mexico and in Africa.

Microenvironmental Factors in Severe Protein-Calorie Malnutrition

Protein-calorie malnutrition (PCM) is a disease complex occurring primarily among the poor in preindustrial societies where the social system, consciously or unconsciously, creates malnourished children, generation after generation, through a series of social misfortunes, among which are limited access to goods and services, limited social mobility, and restricted opportunities for social stimuli at crucial points in life (1).

Early Malnutrition and Auditory-Visual Integration in School-Age Children

are significant indicators of early exposure to primary or secondary malnutrition (Cravioto, 1963; Dean, 1960; Gruelich, 1958; Hiernaux, 1964).2 All children aged 7 through 12 were weighed and measured by a pediatrician especially trained in somatic measurement (Vega, Urrutia, & Cravioto, 1964), and on the basis of height two groups were identified, one representing the upper 25% of the height group for each age and sex and the other the lowest 25°%. This resulted in a total group of 296 children, 141 boys and 155 girls. While general mental status has correlation with measures

THE UTILITY OF CROSS‐SECTIONAL MEASUREMENTS OF WEIGHT AND LENGTH FOR AGE IN SCREENING FOR GROWTH FAILURE (CHRONIC MALNUTRITION) AND CLINICALLY SEVERE PROTEIN‐ENERGY MALNUTRITION

ABSTRACT. The accuracy of identifying children with growth failure and/or clinically severe protein‐energy malnutrition (PEM) from a single measure of length or weight for age from birth to 36 months was determined. Growth data were treated cross‐sectionally and compared with National Center for Health Statistics growth standards in order to determine the sensitivity, specificity and positive predictive value of a single cross‐sectional measure of weight‐for‐age or length‐for‐age in identifying children diagnosed via longitudinal records. Under 6 months of age, neither weight nor length for age was an adequate predictor of growth failure or clinical malnutrition; from 12 to 36 months, screening measures based on anthropometry were much improved. It was concluded that a single measure of weight or length for age taken close to the first birthday could identify up to 78% of the future second and third year cases of clinically severe PEM. Implications and limitations are discussed.

A PROSPECTIVE STUDY OF THE EFFECTS OF CLINICALLY SEVERE PROTEIN-ENERGY MALNUTRITION ON GROWTH

Abstract. School, T. O., Johnston, F. E., Cravioto, J. C. and De Licardie, E. R. (Department of Anthropology, University of Pennsylvania, Philadelphia, USA). A prospective study of the effects of clinically severe protein‐energy malnutrition on growth. Acta Paediatr Scand, 331.—The effects of severe protein‐energy malnutrition (PEM) upon the growth of children was studied in a 13‐month cohort. The serial records of 19 PEM children from the cohort were compared to those of cohort children with the same growth history (either failing or non‐failing growth), but without severe PEM. When the comparison was made on the basis of age, no differences in growth were found except for arm muscle circumference at one age. Using Z‐scores, comparisons were also made according to months before or after the diagnosis of PEM. When compared to children with the same growth history, PEM children showed short‐term differences in weight and arm muscle circumference and a mild retardation in growth in length which was not significant. Any growth effects following the episode of severe PEM were accounted for by growth status preceding its onset.

Longitudinal Study of Language Development in Severely Malnourished Children

At the community level, malnutrition--more specifically protein-calorie malnutrition--is a man-made disorder characteristic of the lower socioeconomic segments of society, particularly of the preindustrial societies, where the social system consciously or unconsciously creates malnourished individuals, generation after generation, through a series of social mechanisms among which limited access to goods and services, limited social mobility, and restricted experiential opportunities at crucial points in life play a major role.