Ronald E. Kleinman

Hunger in Children in the United States: Potential Behavioral and Emotional Correlates

Objective. Results from a recent series of surveys from 9 states and the District of Columbia by the Community Childhood Hunger Identification Project (CCHIP) provide an estimate that 4 million American children experience prolonged periodic food insufficiency and hunger each year, 8% of the children under the age of 12 in this country. The same studies show that an additional 10 million children are at risk for hunger. The current study examined the relationship between hunger as defined by the CCHIP measure (food insufficiency attributable to constrained resources) and variables reflecting the psychosocial functioning of low-income, school-aged children. Methods. The study group included 328 parents and children from a CCHIP study of families with at least 1 child under the age of 12 years living in the city of Pittsburgh and the surrounding Allegheny County. A two-stage area probability sampling design with standard cluster techniques was used. All parents whose child was between the ages of 6 and 12 years at the time of interview were asked to complete a Pediatric Symptom Checklist, a brief parent-report questionnaire that assesses childrens emotional and behavioral symptoms. Hunger status was defined by parent responses to the standard 8 food-insufficiency questions from the CCHIP survey that are used to classify households and children as “hungry,” “at-risk for hunger,” or “not hungry.” Results. In an area probability sample of low-income families, those defined as hungry on the CCHIP measure were significantly more likely to have clinical levels of psychosocial dysfunction on the Pediatric Symptom Checklist than children defined as at-risk for hunger or not hungry. Analysis of individual items and factor scores on the Pediatric Symptom Checklist showed that virtually all behavioral, emotional, and academic problems were more prevalent in hungry children, but that aggression and anxiety had the strongest degree of association with experiences of hunger. Conclusion. Children from families that report multiple experiences of food insufficiency and hunger are more likely to show behavioral, emotional, and academic problems on a standardized measure of psychosocial dysfunction than children from the same low-income communities whose families do not report experiences of hunger. Although causality cannot be determined from a cross-sectional design, the strength of these findings suggests the importance of greater awareness on the part of health care providers and public health officials of the role of food insufficiency and hunger in the lives of poor children.

Relationship Between Hunger and Psychosocial Functioning in Low-Income American Children

OBJECTIVE Using large-scale surveys from nine states, the Community Childhood Hunger Identification Project (CCHIP) estimates that 8% of American children under the age of 12 years experience hunger each year. CCHIP operationalizes child hunger as multiple experiences of parent-reported food insufficiency due to constrained resources. The current study examined the relationship between food insufficiency and school-age, low-income childrens psychosocial functioning. The study also assessed the interinformant (parent versus child) reliability and time-to-time reliability of the CCHIP measure. METHOD Two hundred four school-age children and their parents from four inner-city public schools were interviewed using parent, teacher, and clinician report measures of psychosocial functioning. Ninety-six children and their parents were reinterviewed 4 months later. RESULTS Hungry and at-risk for hunger children were twice as likely as not-hungry children to be classified as having impaired functioning by parent and child report. Teachers reported higher levels of hyperactivity, absenteeism, and tardiness among hungry/at-risk children than not-hungry children. Parent and child reports of hunger were significantly related to each other, and time-to-time reliability of the CCHIP measure was acceptable. CONCLUSIONS Results of this study suggest that intermittent experiences of food insufficiency and hunger as measured by CCHIP are associated with poor behavioral and academic functioning in low-income children. The current study also supports the validity and reliability of the CCHIP measure for assessing hunger in children.

Diet, Breakfast, and Academic Performance in Children

Objective: To determine whether nutrient intake and academic and psychosocial functioning improve after the start of a universal-free school breakfast program (USBP). Methods: Information was gathered from 97 inner city students prior to the start of a USBP and again after the program had been in place for 6 months. Students who had total energy intakes of <50% of the recommended daily allowance (RDA) and/or 2 or more micronutrients of <50% of RDA were considered to be at nutritional risk. Results: Prior to the USBP, 33% of all study children were classified as being at nutritional risk. Children who were at nutritional risk had significantly poorer attendance, punctuality, and grades at school, more behavior problems, and were less likely to eat breakfast at school than children who were not at nutritional risk. Six months after the start of the free school breakfast programs, students who decreased their nutritional risk showed significantly greater: improvements in attendance and school breakfast participation, decreases in hunger, and improvements in math grades and behavior than children who did not decrease their nutritional risk. Conclusion: Participation in a school breakfast program enhanced daily nutrient intake and improvements in nutrient intake were associated with significant improvements in student academic performance and psychosocial functioning and decreases in hunger.

Development of Gastrointestinal Mucosal Barrier. I. The Effect of Age on Intestinal Permeability to Macromolecules

Summary: Indirect evidence has suggested that increased quantities of antigen may penetrate the intestinal mucosa and enter the systemic circulation during the newborn period compared to adult life. However, no direct measurement of macromolecular transport has been reported as a function of perinatal age. To study this process, we administered 100 mg of tritiated bovine serum albumin ([3H]BSA) by gavage to rabbits at birth, one wk, 2 wk, 6 wk, and one year of age and measured plasma radioactivity 4 hr after gavage. Plasma concentration of trichloroacetic acid insoluble radioactivity and immunoreactive bovine serum albumin radioactivity decreased significantly after one wk of age. When adult animals were gavaged with the same amount of [3H]BSA per body weight as the one-wk-old animals, they failed to transport as much of the antigen as the younger animals. This study, therefore, provides objective evidence that the intestinal mucosal barrier of newborns may be incompletely developed at birth and allow increased intestinal transport of antigens into the circulation.Speculation: The development of an animal model for the study of gastrointestinal host defense during the neonatal period may ultimately provide the basis for a better understanding of the mechanisms responsible for intestinal uptake of antigenic molecules and their contribution, if any, to the pathogenesis of human disease. Of particular importance is the accurate quantitation of immunologically reactive antigen absorbed by newborn animals. Using immunologic techniques to quantitate macromolecular transport, it can be determined whether conditions (enteric delivery of nutrients, growth factors in natural milk, etc.) thought to stimulate intestinal epithelial cell turnover can also accelerate the development of the intestinal mucosal barrier and thereby contribute to the protection of the infant from potentially harmful luminal antigens.

Use of infant formulas in infants with cow milk allergy

Allergic (immune‐mediated) reactions to cow milk and other dietary proteins encountered during infancy are responsible for some of the adverse symptoms and syndromes observed in infants intolerant to cow milk, infant formulas and occasionally human milk. Iron deficiency anemia associated with gastrointestinal blood loss, protein losing enteropathy, enterocolitis, colitis, and malabsorption syndrome are examples of putative allergic reactions to dietary antigens which occur in infancy. A number of symptoms referable to the gastrointestinal tract such as, vomiting, colic and chronic non‐specific diarrhea occur in infants both with and without immune‐mediated reactions to dietary antigens. Verification of adverse reactions to dietary antigens, including allergic reactions, should be accomplished through the use of double‐blind, placebo‐controlled food challenge, with the dietary antigen to be tested presented in a liquid vehicle or, in older children, in capsule form. Approximately 8%–25% of children with immediate hypersensitivity to cow milk have been found to be allergic to soy products. Soy and other intact protein substitutes for cow milk, such as beef and lamb based formulas, have produced anaphylactic reactions both in human infants and in animal models. Hypoallergenic formulas should have a chemically modified protein base which demonstrates significant reduction in anti‐genicity when tested in the laboratory both in vitro and in vivo. Such formulas should meet rigorous standards for hypoallergenicity in clinical testing in human allergic infants or infants at high risk for developing allergy before being labelled hypoallergenic.

Association Between 100% Juice Consumption and Nutrient Intake and Weight of Children Aged 2 to 11 Years

OBJECTIVE To investigate the associations between 4 categories of daily 100% juice consumption (0 fl oz, > 0 to < or = 6 fl oz; > 6 to < 12 fl oz; and > or = 12 fl oz) and nutrient and food group intake and weight in children. DESIGN Cross-sectional study. SETTING Secondary analysis of the 1999-2002 National Health and Nutrition Examination Survey data. PARTICIPANTS Children 2 to 11 years of age (N = 3618). MAIN EXPOSURE Juice consumption. OUTCOME MEASURES The association between juice consumption, nutrient intake, food group consumption, and weight status was determined as was the likelihood of overweight with juice consumption. RESULTS Mean daily juice consumption was 4.1 fl oz, which contributed a mean intake of 58 kcal (3.3% of total energy intake). Compared with nonconsumers, the overall nutritional profile of those consuming 100% juice had significantly higher intakes of energy, carbohydrates, vitamins C and B(6), potassium, riboflavin, magnesium, iron, and folate and significantly lower intakes of total fat, saturated fatty acids, discretionary fat, and added sugar. Children consuming 100% juice also consumed significantly more servings of total whole fruit than nonconsumers. No significant differences were found in weight status and the amounts of 100% juice consumed. There was no difference in the likelihood of being overweight between juice consumers and nonconsumers. CONCLUSIONS On average, children consumed less than the maximum amounts of 100% juice recommended by the American Academy of Pediatrics. One hundred percent juice consumption was associated with better nutrient intake than in the nonconsumption group and was not associated with weight status or the likelihood of being overweight in children 2 to 11 years of age.

The enteromammary immune system

SummaryThe discovery that secretory IgA was the predominant immunoglobulin in external secretions stimulated a great deal of research into the secretory immune system and in particular into the relationship between oral immunization and the appearance of antibody at distant epithelial sites such as in the oral cavity and breast. It has become clear that there is a continuous traffic of plasma cells between the gut-associated lymphatic tissue into the systemic circulation and then back to the gut to provide local secretory immunity and also to distant sites again to provide the same specific immunity. Most often the effects of immunization within the system are not reflected in the serum. Deficiencies in this system of external protection are reflected in increased incidences of autoimmune diseases, allergy, diarrheal disease, and cancer in those people with absent secretory IgA. With better understanding of those pathways involved in homing and induction of SIgA, such as the function of hormonal influences on the population of the breast glandular epithelium, the diapedesis of cells from the breast into the colostrum, and the influences of T cells and macrophages presented to the newborn in the colostrum, it may be possible to influence the course of inherited or acquired diseases whose pathogenesis is influenced by decreased enteric immunity. We now also have the possibility of using the passive immunity given by breast milk to protect infants against a number of infectious diseases and toxins to which they are particularly vulnerable, such as neonatal meningitis and food allergy.

Nutrition support for pediatric patients with inflammatory bowel disease: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology And Nutrition.

Impairment of growth and malnutrition are significant complications of inflammatory bowel disease (IBD) in pediatric patients. Since this topic was last reviewed in these pages (), a number of studies have further explored the epidemiology and pathogenesis of these nutritional complications of IBD in an effort to provide more effective interventions to prevent the long-term consequences of chronic nutrient deficiencies in childhood. In addition, during the past 15 years, the use of selected nutrients and microorganisms (probiotics) as primary or adjunctive therapy for the treatment of IBD has become an emerging area of great interest. The following is a Clinical Report from the Nutrition and Inflammatory Bowel Disease Committees of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

Nutrition and performance in children.

Purpose of reviewMalnutrition in late infancy and childhood remains a significant public health issue in developing nations as well as for those in transition to an industrialized economy. In addition, in these settings and particularly in developed nations, overweight is becoming a very serious threat to both the immediate and the long-term health of children. In this review, we present recent studies that have examined relationships between childhood undernutrition and three general areas of performance: physical activity, cognition and behavior. Recent findingsMalnourished children have been shown to have decreased physical activity and endurance, and poorer cognitive function and school performance. Multiple single micronutrient deficiencies, including vitamin B12, thiamin, niacin, zinc and iron, have been associated with poorer cognitive performance. Behavioral problems, including attention deficits, have also been associated with food insufficiency and malnutrition. SummaryThe effects of impaired nutritional status during childhood may have long-standing consequences for the health and performance of children during their adult years.

Consumption of whole grains is associated with improved diet quality and nutrient intake in children and adolescents: the National Health and Nutrition Examination Survey 1999–2004

OBJECTIVE To examine the association of consumption of whole grains (WG) with diet quality and nutrient intake in children and adolescents. DESIGN Secondary analysis of cross-sectional data. SETTING The 1999-2004 National Health and Nutrition Examination Survey. SUBJECTS Children aged 2-5 years (n 2278) and 6-12 years (n 3868) and adolescents aged 13-18 years (n 4931). The participants were divided into four WG consumption groups: ≥ 0 to < 0·6, ≥ 0·6 to < 1·5, ≥ 1·5 to < 3·0 and ≥ 3·0 servings/d. Nutrient intake and diet quality, using the Healthy Eating Index (HEI)-2005, were determined for each group from a single 24 h dietary recall. RESULTS The mean number of servings of WG consumed was 0·45, 0·59 and 0·63 for children/adolescents at the age of 2-5, 6-12 and 13-18 years, respectively. In all groups, HEI and intakes of energy, fibre, vitamin B6, folate, magnesium, phosphorus and iron were significantly higher in those consuming ≥ 3·0 servings of WG/d; intakes of protein, total fat, SFA and MUFA and cholesterol levels were lower. Intakes of PUFA (6-12 years), vitamins B1 (2-5 and 13-18 years), B2 (13-18 years), A (2-5 and 13-18 years) and E (13-18 years) were higher in those groups consuming ≥ 3·0 servings of WG/d; intakes of added sugars (2-5 years), vitamin C (2-5 and 6-12 years), potassium and sodium (6-12 years) were lower. CONCLUSIONS Overall consumption of WG was low. Children and adolescents who consumed the most servings of WG had better diet quality and nutrient intake.