Am J Clin Nutr 1973 Pollitt 264 70

8/13/2019 Am J Clin Nutr 1973 Pollitt 264 70

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eh v io r o f in f n t in c us tion o f

26 4 The Am erican Jo urn a l o f C lin ica l N u trition 26 : M A R C H 19 73 , pp . 2 64-27 0 . P rin ted in U .S .A .

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nu tr itio n l m r sm usErn es to Po lllu ,4 P h .D .

M ost in vestiga to rs recog n ize cau sa lity inseve re p ro te in -ca lo rie m a ln u tritio n , e spe -cia lly in n u tr itiona l m arasm us, a s be ing com -p lex and m ultifacto ria l (1 -3 ). H eg sted (4 )po in ts ou t tha t in vestiga to rs accep t d iffe ren tfac to rs a s s ign if ican t an d acco rd them dif-fe ren t e mpha s i s . F ac to rs inc lude inadequ a tequ an tity and q ua lity o f fo od , po ve rty , anun satis fac to ry p hysica l and psy ch oso cia l en -v ironm en t, an d pa ren ts w ho a re igno ran t o fapprop ria te ch ild ca re .

T he m a jo r cause o f p ro te in -ca lo r ie m al-nu tr ition is genera lly p laced in fac to rs o f th ep hys ica l, b io log ica l, and soc iopsycho lo g icalenv iro nm ent. E xcep t fo r no ting ano rex ia as acon trib u to ry fac to r , th e behav io r o f the ho stis no t taken in to accoun t. T h e im press ion le ftis usua lly tha t o f a he lp less in fan t adverse lya ffec ted by the v ic iss itudes of a life inp ove rty . S u ch a un ila te ra l exp lan a tio n o fcausa lity resem bles soc iopsycho log ica l m o d-e ls com m on ly used to exp la in o r p red ictch ild behav io r. M os t o ften th e ch ild is seen asun id irec tiona lly a ffec ted by paren ta l in flu -en ces w ithou t accoun ting fo r the po ss ib ilitytha t pa ren ta l so cia liz in g behav io r cou ld bep artly d ep en den t u pon co nstitu tio na l o r tem -p e ram en ta l ch aracte r is tics o f the ch ild 5 , 6 .

D is reg ard for th e be hav ior of the ch ild asa h ost is surp rising b eca use of pub l ishedrepor ts tha t nu trit ion ally m arasm ic hildrenare w eaned ear ly , r e ommonly th e off -spring of g ran dm ultiparous w o m e n w ith ah isto ry of c lo sely sp aced p regn an cie s , anda re like ly to h ave lo w b irthw e igh ts .

T h ese cha rac ter is tic s sho u ld su ggest tha tsuck ing b eh av io r, leve l o f a rousa l, and in ter -re la tio nsh ip s w ith the m other a re adv erse lya ffec ted in the in fan t p r io r to th e d ev elo p -m en t o f m a lnu trition . In tu rn , su ch co nd i-tio ns p rob ab ly h inde r foo d in take an d th ere -fo re a ffec t nu tritio na l sta tu s .

T h e pu rp ose n ow is to p resen t ava ilab le

da ta re lev an t to the issu es ra ised abov e andto p ro pose th e hyp o th esis th at b ehav io r o fthe in fan t in f luences occu rrence o f n u tr itiona lm a r a s m u s .Mult ipar i ty

R ep orts from d ev e lop in g coun trie s o nfam ily cha rac te ris tics o f ch ild ren w ith seve rep ro tein -ca lo r ie m a lnu tritio n o ften sh owm any m alnourished in fan ts to be la te -bornch ild ren o f grandm ultipa rous w om en . As tud y of 22 cases o f ty p ical m arasm u s inP e ru g ives ev id en ce tha t 41 w ere s ix th o rla te r bo rn , and a ll o f these w ere th e las t borno f a fam ily . O f 55 cases o f kw ash io rko r , 88w ere th ird o r la te r b orn (7 ) (T ab le 1 ). InC o lom bia , 4 9 o f 14 5 ch ild ren w ith p ro -te in -ca lo rie m aln u tr ition w ere six th o r late rb o rn . B y con tra st, T ab le 2 sho w s tha t on ly37 of 38 6 ch ild ren w ho w ere fifth o r ear lie rborn h ad a sim ila r cond ition P < 0 .05 (8 ) .

C lose ly spaced p regna nc iesO the r rep orts dem on stra te a c lose asso -

c ia tion b etw een prescho o l m alnu tr ition andc lo se ly spaced p reg nanc ies o f the m other. InJo rdan , 78 of the m others o f m alnour ishedch ild ren w eaned th eir b ab ie s b ecause o f newpregnan cies (9 ). A s ig n ifican t pos itive cor-re la tion be tw een num bers o f p resch oo l ch il-d ren in the fam ily and p re schoo l m aln u tritio nw a s a lso fo und in th e C o lo m bian study ci ted .O f 79 ch ild ren w ith fou r o r m ore p re schoo l

the D epa rtm en t o f N u tr ition and F o odScience , M assachu se tts In stitu te o f T echno log y ,C am bridge , M assa chu set ts 02139 .

T h is pu b lica tion is con tribu tion N o. 200 0 fromthe D ep ar tm en t o f N utrition and Foo d S c ien ce.

b y P ub lic H ea lth S erv ice C on trac tN o . N IH 7 1 -2417 w ith the N atio na l Institu tes o fC hild H ea lth and H um an D eve lopm ent, B e thesda ,M ary land 20 014 .

4A ssoc ia te P ro fesso r o f G ro w th and D eve lop-m en t, D epartm en t o f N utrition and Fo od Sc ience .


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CA U SA T IO N OF N U T RI T I ON A L M A RA SM U S 2 6 5

sibl i ngs, 47.9% w ere malnouri shed, w hereas352 w i th three or less preschool sibl i ngs hada f requency of only 29% (8) (T able 2).

In a study of undernutr i ti on and mentaldev elopment in C olorado (10), sim i lar pat-terns occurred; e.g., 19 chi l dren adm i tted tothe D env er G eneral H ospi tal w i th general -ized undernutr i ti on w ere compared for se-lected social f actors w i th m atched control s ofsimilar economic l ev el . O ne di f f erentiati ngsocial factor w as the stress of one or tw o sib-l ings l ess than 2 years old. T hese f indingsw ere corroborated in a study on the ef fect ofsocioeconomic and cul tural i nf l uences onchi l d grow th in the v i l l age of L aw rence T av-em in Jam aica (1 1).Low b irthw e igh t

T here are few er than a handful of studieson bi r thw eights of severel y m alnouri shedchi l dren. T hat lack i s w hol l y understandable,gi v en the general l y low education of m others,the unrel i abi l i ty of retrospecti ve data, andthe inadequacy of cl i ni cal records in hospi tal sserv i cing rural or low incom e areas (12).M oreov er, prospecti v e studies in w hich thecase histor ies of low bi r thw eight chi l dren aref ol l ow ed unti l they become severel y m al -nour i shed are rare because of obv ious moralimplications. Some publ i shed data suggestthat chi l dren w ho become severel y m al -nouri shed of ten had low w eights at bi r th. Forexam ple, i n the C olorado study (10), 10 ofthe 19 cases w ith general i zed undernutr i ti onhad bi rthw eights of 2,500 g or less. A sam pleof m alnouri shed chi l dren al l w i th bi rth-w eights above 2,500 g is reported byM onckeberg (13). H is sample of 14 hospi -tal i zed malnouri shed chi l dren had a range inbi r thw eight f rom 2.9 to 3.8 kg (i n = 3.4).

D espi te reports to the contrary , i t i s i ndeedprobable that the inci dence of prem aturi tyor low bi rthw eight am ong nutr i ti onal l ymarasm ic chi l dren is greater than that for thegeneral populati on. T his inf erence is sup-ported by inf orm ation of adverse ef fects ofhigh pari ty and short spacing betw een preg-nancies. A considerable amount of researchdata show s an increased reproducti v e ri sk ,m ost marked in low income groups (14), asa function of par i ty . B i rch and G ussow (14)show f rom a rev iew of relev ant studies that,

T A B L E 1Fam i l y si ze and bi rth order of pati ents w i thkw ashiorkor and nutr i ti onal m arasmus i n Perua

T yp e of m al nut ri ti onCharacteristics

K w ash- M arasmusiorkor (typical )

N o. of casesC hi l dren in f am i l y

A verage num berA ge r a n g ePatients order of birthbFirst bornS e c o n dTh irdFourthFi f thSi x th or l aterL ast born

513.9

2 1 01 (3)5 1 5

15 (44)6 (18)3 (9)4 (12)

28 (82)

225.0

2 1 2

1 (5)6 (27)6 (27)9 (41)

22 (100) From (7). T w o aty pi cal cases oim arasm us

are not i ncl uded (see tex t). N um bers in parenthesesare t he p er cen tag es.T A B L E 2A ssociation of protei n-calori e m alnutri ti on i npreschool chi l dren w i th bi rth rank and num ber ofpreschool chi ldren in f am i l y i n Colom biaa

PCMD em ographic f actor

Popula-tion incategory N um-ber Per-cent

P

B i rth rank5th or l ow er 773 286 37.0


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266 owrrA ccordingly , there i s justi f i cati on f or in-

ferri ng that a considerable proporti on ofseverel y malnouri shed chi l dren are prema-ture or have low er bi rthw eights than thepopulation average. T he incidence of m al -T A B L E 3M ean bi rthw eights accordi ng to socioeconom icstatus (I ndia, Congo, Ghana, and I ndonesia)

MeanPlace Population Subjects status bi rth-w eights, g

M adras Indian Well- to -do M ostl y poor 2,9852,736South India I ndi an W eal thyPoor

3,1822,810

Bombay

Calcutta

Congo

Indian

Indian

Bantu

U pper classU pper m iddle

c l a s sL ow er m iddle

c l a s sL ow er classPay ing pa-tientsPoor class V e r y wel l -nourishedWe l l -nou r -

ished B adly nour-

i s h e d

3,2472,9452,7962,5782,8512 6 5 63,0262,9652,850

Ghana (A c-PygmiesA fri can Prosperous

2,6353,188

cra) General popu-l a t i o n

2,879Indonesia Javanese W el l - to-do 3,022(Jogjakarta) Poor 2,816

A dapted f rom (18).

T A B L E 4M ean bi r thw eight of new borns i n A f ri ca andt ra1i s- Sahar an t er ri to ri es

Place M ean bi rt hw ei g bts, kg

Congo (M ayum be) 6 l b, 7 oz (2.92)Ni g e r i a (Ibadan) 6 lb, 5 oz6 lb, 6 oz (2.86)(2.89)N igeria (L agos) 6 lb , 13 oz

6 lb, 10 oz(3.90)(3.01)Nyasaland, rural 6 lb, 9.5 oz (2.99)South A fri ca (D urban) 6.77 lb (3.07)

Southern R hodesia (Sal i s- 6.3 lb (2.86)bury)U ganda (K am pal a) 6 i b, 8 oz (2.95)a A dapted f rom (19).

Malawi .b N ow k now n as

nutri ti on i s greater in dev eloping countr i es ori n low incom e areas w here bi rthw eights aver-age less than in dev eloped countri es or inhigh i ncom e areas (17, 1 8) (T ables 3, 4).L ow bi rthw eight in developing countries andi n low i ncom e areas apparentl y resul ts f romretarded i ntrauteri ne grow th stem mi ng f romdi sturbances in f etal nutr i ti on (16, 19). I faverage bi rthw eights of severel y malnour-i shed chi l dren fal l on the negati v e side ofdi str i buti ons of populati on bi r thw eights, theyare l i kel y to be signi f i cantl y below the W H Ocutof f point (2,500 g) for prem aturi ty .Ear ly w ea n ing

A f ew reports also show earl y w eaning innutr i ti onal m arasmus: f or example, com -pari ng his experience w i th m arasm us tokw ashiorkor i n Jordan, M cL aren says thatM arasmus has a m ore com pl ex basicetiology w i th a monotonously constant pat-tern of ear l y w eaning (9). I n the Peruv ianstudy of 22 cases of ty pi cal m arasmus, anaverage duration of only 2.0 m onths of ex -clusive breast f eeding w as recorded; i nkw ashiorkor i t w as 7.8 m onths.

M alnutri ti on appears to develop slow lyas breast f eedi ng ends, and the diet there-af ter fai l s to meet the nutr i ti onal requi re-m ents of the infant. T here i s need f ordetai l ed interdi scipl i nary surv ey s into thedy nam ics of ear l y w eaning (20).Behav io ra l e ffe cts

From a rev iew of a series of studies onpari ty and closely spaced pregnancies, W al -drop and B el l (21) concluded that inef f ectual ,dependent, im mature behav ior in chi ldrenw as associ ated w i th m any closely spacedsibl i ngs. T hey then developed the hy poth-esi s that inf ants born to m others w ho hadexperienced a large num ber of closely spacedpregnancies w ould be lethargi c. Speci f i cal l y ,they w ere interested i n w hether new bornsf rom large, densel y concentrated f am i l i esw ere i nef f i ci ent in obtal ning nourishm ent asmeasured by suck rate and num ber of sucks,would cry l i ttl e, and w i th low i ntensi ty evenw hen uncomf ortable and hungry , and w ouldbe sl ow to respond to a sti mulus such as therem oval of a nipple on w hi ch they w eresucking.


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CA USA TI ON OF N U T RIT ION A L M A R A S M U S 267

W aidrop and B el l dev eloped a com posi tescore as a f am i l y si ze and densi ty index(FSD ). I t i ncluded: 1 num ber of children,2 average span in m onths betw een bi rths,and 3 m onths to the next older sibl ing. T heyobserved the behav ior of 74 inf ants born tomul tiparous w om en, and onl y chi ldren w i thw eights over 2,500 g w ere i ncluded in thesample.

T he FSD index correl ated negatively w i thsuck ing behav ior and total cry ing but posi -ti vel y w i th lethargy . L ethargy w as based ona composi te score that included suck ing rate,total cry ing, and ini ti al reaction time. Fam i l ysize and densi ty index proved a rel iablepredictor of f ood intake. Furtherm ore, sig-ni f i cant posi ti ve correlati on developed w hen2. 5 years later, FSD scores w ere testedagainst a nursery school rati ng of contactw i th a f em al e teacher r = + 0.36; P

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Am J Clin Nutr 1973 Pollitt 264 70