GHANA MEDI MARCH 1990 VOL. 24NO.1 37-42 NUTRITION ‘Tuesday 8th August 1989, Morning Session Chairman: Prof. E.Q. Archampong; Dean, University of Ghana Medical School. Co-Chairman: Prof. K. Kishi; Department of Nutrition, School of Me Japan. ine, University of Tokushim NUTRITION AND CHILD DEVELOPMENT J.0.0. Commey Department of Child Health, University of Ghana Medical School, Legon, Ghana. f the world’s present population of nearly Community or mass malnutrition in particul 4,400 million about 38% are children is a man-made problem especially common is under the age of 15 years. On current average, the segments of the population beyond or 125 million children are added to the world away from the economic, social, and politi each year. decision making. Malnutrition has been am remains the unwanted co-inhabitant of infants Only one-quarter of the world’s children live in young and pre-school children and pregnan developed countries where there exists sig- and nursing mothers, who indeed are the ve nificant degrees of compliance with the Decla- people with increased need for food and ener ration of the Rights of the Child adopted by the ey: General Assembly of the United Nations in 1959. The 4th Principles of the Declaration in particular states inter alia that Considerable interest has always existed in th question as to whether early malnutrition 4 fects the human brain and hence its major fune tion, the human intellect and development) Whereas the developing brain is very sus tible to the effects of undernutrition, the adt or matured brain seems to exhibit almost com plete immunity to damage. At the point d death from prolonged starvation adults. wh may have lost almost half their body weig often do not show any detectable changes brain weight or composition. Since man developmental events in the brain have onl ‘one opportunity to occur at certain chronolog (a) The child shall be entitled to grow and develop in health through the provision of special care and protection to him and his mother both antenatally and after delivery. (b) The child shall have the right to adequate nutrition, housing, recreation and medical services. Both specialists and laymen alike agree that a qualitatively and quantitatively adequate cally defined times, if conditions for their sus dietary intake is of prime importance in man’s cessful accomplishment are not optimal at th life while in the child it is practically a prereq- appropriate time, the opportunity will uisite for optimal growth and development. In- forever lost, so that the brain will remain pet deed, nutrition is the only omnipresent factor in manently deficient in the particular resped matters of man’s health and well-being. The immensely intricate developmental se 37ence in the brain unfortunately provides little opportunity for the achievement of compensa- afor disturbances during its course. in humans, the brain’s growth spurt lasts from 13th week of gestation until at least the end the second year, though in areas where mal- ion is prevalent, the high risk period for in damage may extend from the period of ning to the end of the pre-school years. ce most infants who have suffered from foc- malnutrition are likely to be exposed to | undernutrition and high levels of in- ion, it is hardly surprising that such affected ‘life, hence the high infant mortality rates of the poverished, uneducated developing nations.” . among the fortunate survivors, the ituration of critical tissues like the brain cor- and neuronal cell function may be limited, ding to defective development with a poorer of catch-up should nutrition be sub- equently improved to optimum levels. diate pre-pregnancy sesh Work from Guatemala among impoverished rural com- munities, has shown direct correlation between tthe caloric value of supplementary food during pregnancy and average birth weight. Women ing food supplements had bigger babies § on average, than women without supple- Persistent female undernutrition during pregnancy is invariably associated with "varying degrees of foetal malnutrition leading ‘to the birth of infants who at term are too small for gestational age (i.¢. birth weight under 2.5kg, or SIbs). Low birth weight newborns are on the increase in our dear nation as well as other poor countries because of the increase in teenage pregnancies, the declining economic dimate, the high maternal fertility rate and the “rather limited success of our family planning “strategies for birth spacing and family size _ limitation. NUTRITION IN CHILD DEVELOPMENT Unfortunately in most developing nations childhood undernutrition persists in variable degrees into adulthood with considerable ef- fects on the social variables of physical stature, mental function, work capacity, fertility and reproduction. Worldwide, the commonest cause of being small at birth and short in later childhood is malnutrition. Often malnourished babies and children in developing countries are given some nutritional rehabilitation in hospi- tals, special nutritional out-patient clinics or by the distribution of supplementary foods in the community. These children unfortunately al- ways go back or continue to stay in their original nutritionally deficient environments. While little proof exists to indicate that mal- nutrition in infancy and carly childhood leads to permanent stunting of growth, undernutri- tion during late childhood and’ adolescence can, however, result in adults who are short in stature. Whereas Indian workers” have ob- served no handicap in studied malnourished in- fants, particularly in locomotor function, and adaptive or social behaviour, others have sug- gested a different outcome. Accepting the premise that cross-species extra- polations to humans may be fraught with dif- ficulties, a notable comparison still exists, where anti-social traits such as aggression, dominance and even unsociable behaviour not infrequently seen in previously malnourished children have also been noted commonly in animals subjected to variable periods of under- nutrition, Undernourished children have been noted to spend only 15% of a given period of time on daily activities such as walking or run- ning whereas normal children spent 35% of such time, thus affecting their exploratory be- haviour and perhaps céntributing to a lack of initiative and drive in adulthood. The charac- teristic apathy and irritability of the child with kwashiorkor may suggest _ significant psychomotor derangement but its persistence after recovery is debatable. Psychomotor tests in children after recovery from kwashiorkor have shown defects in sensory integration which could eventually interfere with learningMARCH 1990 processes. Electro-encephalographic changes seen in kwashiorkor are known to persist for several months. The uncertainty about malnutrition and mental development, particularly poor performance in mental tests, is compounded by the fact that malnutrition generally appears in the context of poverty, poor general health, and lack of intel- lectual stimulation, which conditions by them- selves are known to affect mental development adversely. Recently several studies from Latin ‘America (in particular Colombia, Guatemala and Mexico) have tended to suggest that children who haye suffered from chro protein-energy malnutrition, even in a mild to moderate degree, arc likely to fail to reach their true intellectual potential. The effect of undernutrition on educational wastage has not been studied closely in most developing countries. In Ghana in particular, the system of mass promotion every year has led to the common situation of finding older children in senior elementary school classes who are incapable of doing class exercises meant for much younger pupils such as spelling their own names or solving rudimentary mathe- matical problems involving addition and sub- traction. The school problems of such pupils however, may be affected by other notable vari- ables including lower parental background and income and a social environment devoid of any meaningful stimulation (i.e. when the violence and other deviant behaviour common on the private video screens in our cities today is ex- cepted). There is a high school drop-out rate as evidenced by the increasing numbers of children and young adults engaged in the economic field as bookmen, lorry mates, load carriers at our city markets and "dog chain" sellers on our city roads. The unsatisfactory level of learning at school, the repetition of the first school year particularly in the standard conscious private preparatory schools, and the J.0.0. COMMEY Ee GHANA MEDICAL JOURN: high drop out rates are invariably the poss consequences of impaired development. early malnutrition is, at least in part, a factor poor performance, there is little justification i investing large sums (either by government g directly by parents) on the improvement d educational systems in isolation from other tems, In a nutshell, if children of low soci¢ economic status (in fact our whole nation) to benefit from the increased government vestments in education, their chances of scho success must be improved by attacking sud basic problems as carly protein energy mi nutrition as well as the provision of whole: nutritious and inexpensive foods in satisfactoy quantities to our students. The association by tween early malnutrition and suboptim learning during childhood and adolescenc! especially among families with social disad vantage, may contribute to inequity in empl ment opportunities, lower productivity, lowe income, and poor quality of life. Since programmes of national development, chat teristics such as initiative, receptivity to, understanding of technological innovation the critical determinants in both urban rural populations, it is the human quality rath than physical work per se that become more i portant for social and economic development The government's current educational reform aim at the expansion of the formal educatic systems as has traditionally been encouraged international agencies, often without consid tion of the complex inter-relationships bet the factors involved in development, and usud ly in the light of clear evidence that in the Ie developed countries like our own mal children never attend school, or attend for short time only, or fail their examinatial repeatedly. Is it possible that an increase: educational opportunitics alone will r educational attainment? Paediatric practice the world over but more: in the developing world is much concerned adequate and proper feeding of children. Fj people, however, to eat well it is necessaryagricultural technology, methods of storage; particularly 2 i) the choice of essential cash and staple | crops for cultivation and ‘the purchasing power of families, espe- cially the womenfolk. nadequate nutrition is commonly associated ‘with multiple social variables including: Iliteracy or poor general educational level - unsuitable traditional modes of child care importance attached to and attitudes _ towards basic education low income resources poor living conditions, including inadequate sanitation, and "= overcrowding and insufficient experiences in stimulating child growth and develop- ment. ‘Adequate postnatal nutrition can be achieved in every corner of the world JF ONLY mothers ‘Would feed their young children with foods that are readily available in the community ic. ‘breast milk and local staples appropriately "prepared for the individual child from enriched d combinations like weanimix in Ghana. Breast milk remains the most important source f nutrition for the newborn, the young infant and even some toddlers. Any baby whose mother is absent usually through death at child birth or whose mother docs not secrete breast milk will have a poor chance of survival. In "particular it needs to be stressed that adequate milk production by the mother is not necessari- lyassociated with adequate breast feeding since ill-health and structural abnormalities of the babies oropharynx or the mother’s breasts such as retracted nipples or excessive breast engor- NUTRITION IN CHILD DEVELOPMENT gement may interfere with the sucking reflex and lead to severe inanition in the presence of adequate and often excessive amounts of breast milk. In areas like ours where mothers and often fathers have restricted or limited educa- tion, where health education for mothers is poor, where personal and environmental hygiene are of low standard, the maintenance of breast feeding is critical for adequate nutri- tion and survival. Breast feeding through its reduction of the risk of infection with organisms like E. coli, Shigelta, Salmonella and Vibrio cholera greatly reduces the incidence of acute diarthoeal diseases which together with acute respiratory infections predispose to undernutrition, These three dis- orders together are responsible for more than 50% of all deaths in children aged 0 - 5 years. Breast feeding promotion is the responsibility of all health professionals involved with the child from his very origins -notably gynaecologists and obstetricians, midwives, traditional birth attendants, public health nur- ses, general duty doctors and nurses, nutritionists and various women’s groups. The practice of establishing contact between mother and child within minutes of delivery has been associated with an increased likelihood of successful lactation and breast feeding as well as a much closer bonding between mother and child. This bonding is associated with a much lower incidence of emotional disturbances. A fairly recent prospective study in Accra found that only 33% of sick pre-school children attending hospital with various medical condi- tions were adequately nourished, Among the malnourished children 21.5% had moderately severe undernutrition in the form of kwashiorkor (14.2%) and/or marasmus (7.3%). Fifty-eight percent of these malnourished children were also stunted indicating malnutri- tion of some considerable duration’. Earlier, community studies since 1961 by the National Nutrition Survey had similarly shown that 18% of all children aged 5 months to 5 years had moderate to severe malnutrition, Recent datafrom various growth monitoring centres sup- ported by the Catholic Relief Services have suggested that the malnutrition rate is worsen- ing with the percentage of underweight children (i.e, weight-for-age below 80% of the median of the Harvard standard) having in- creased from about 35% in 1980 to 51% in 1985'. Significantly, inappropriate weaning practices have been identified as a major causa- tive factor. Too early supplementation of breast feeding with low-energy cereal grucls with little or no protein enrichment was par- ticularly common. Many Ghanaian mothers appear to be unaware of what optimum growth should be while fewer still think that the quality of food is important. Furthermore, mothers in general do not seem to be adequately aware of the amounts of food that children eat or should be eating. While the frequency of feeding is low, the quality and amount of meals also tend to be low, so that the diet of most one-year-olds across the country is inadequate in every respect to maintain health and for growth. Growth monitoring, and the growth curve offer an opportunity to demonstrate desirable growth. It is significant to note that some forms of growth monitoring had been practised by our mothers in previous times through the application of beads of vary- ing colours and sizes worn around designated areas of the child’s body such as the wrists, the neck and the waist. The Village Nutrition Ac- tion Programme (VNAP) currently in vogue in Thailand” and other far Eastern countries needs scrious consideration for adoption in our communities. VNAP basically aims at training village mothers to the midwife level of proficiency in the weighing of infants and young children as well as the recording of weights on charts and the interpretation of growth charts. These mothers then meet once a month to weigh their own pre-school children, plot their weights on charts and discuss why one child had gained, another lost or yet another remained stationary in weight; and finally decide on what measures are needed to correct the noted deviations. Food supplementation here is through mutual help from the con- 1.0.0. COMMEY 4 cerned mothers themselves, each according how much surplus food she can release to needy neighbour. This system appeals to me being very suitable for Ghana where our mo: successful mothers in the communities cot help those at social disadvantage through j training, temporary employment and hand-or of food, used clothing and study aids for children in poorer circumstances. Infant and childhood illnesses (particul: diarrhoeal diseases, measles and whoopi cough) also interfere considerably wi childhood nutrition, even among the well to through energy losses. Complete immunizati of the pre-school child and the adoption of or rehydration therapy as the cornerstone of di thoea management have beneficial effects childhood nutrition. The time has come health authorities and all those who care for welfare of the child to convince natio economic planners of the beneficial effects good nutrition by attempting to quantify: (@ the lives that can be saved the diseases that can be prevented, and the quality of life that can be attai through better nutrition. REFERENCE 1. Lechtig A, Delgado H, Lasky R, Yarbro C, Klein RE, Habicht JP, Behar M. Mater nal Nutrition And Fetal Growth Developing Countries. Amer. J. Dis. Chi 1975; 129: 553. 2. Ghosh, S. et al. Growth and development babies with severe intrauterine gro retardation. Proc. Nutri. Soc. India 1972; 11: 1-8. 3. Commey JOO, Amuasi GAS, Richar: JE, Asamoah-Baah A. The nutritio status and feeding practices among siMARCH 1990 urban pre-school children admitted to a major hospital in Accra, Ghana. Annals Trop. Paediat. 1985; 5: 131 - 136. Nutrition Division, Ministry of Health, Ghana. Improving Young Child Feeding Practices in Ghana, 2: 1989. §, Amorn Mondasuta. Nutrition: A health sector responsibility. World Health Forum 1984; 4: 18 - 20. Thank you very much indeed Dr. ommey for this very illuminating exposition. Normally, we do not subject our keynote speakers to questions or ask for comments, but vill make an exception of this. I know that ny co-chairman has a comment and perhaps a juestion. Co-Chairman: Thank you very much Dr. Com- for the fine lecture. I would like to know thing about supplementary feeding programmes of children, Do you have any nationwide supplementary feeding programme {for children, like a school lunch programme? ‘Speaker: ‘Thank you very much Prof. Kishi for ‘the question. There have been some forms of ipplementary feeding in Ghana over the last few years. I quite remember that when we were in secondary school, way back in the late 50's, and early 60’s secondary students were given 42 NUTRITION IN CHILD DEVELOPMENT milk drinks and then even the primary school programmes were also given food, But when we have tended to evaluate the supplementary feeding programmes, it has become clear that only about a quarter of what is meant for the children who need it is going to the children, and that adults feed fat on part of it, and the majority of what is given is actually taken by the employees and sold on the market. If we were to go back to the recent experience with the James Town Nutritional Programme Rehabilitation, the teenage mothers who have got two children at the age of fifteen and are obviously not in a position to feed them be- cause of all of them are malnourished, come regularly to the clinic on Tuesdays to collect milk packages. But they sold these milk pack- ages in small parts to adults who want to drink tea with milk, We are now beginning to say that, we do not readily support the Food Sup- plementation as it is being currently given out. ‘And infact our sister country Nigeria, will not like to hear about it at all. Co-chairman: That is rather a disturbing note I think, Should we not perhaps think of this within the context of improvement all round rather than stopping something that has promise for the risk group because of the possibility that it might get sidetracked. We should not let the risk group continue to suffer. But this is perhaps a matter for more general consideration,