Effect of a food supplementation and psychosocial stimulation trial for severely malnourished children on the level of maternal depressive symptoms in Bangladesh.

BACKGROUND: Maternal depression is associated with poor child development and growth in low-income countries. This paper evaluates the effect of a community-based trial providing psychosocial stimulation and food supplements to severely malnourished children on maternal depressive symptoms in Bangladesh. METHODS: Severely underweight (weight-for-age Z-score < -3) hospitalized children aged 6-24 months (n = 507), were randomly assigned to: psychosocial stimulation (PS), food supplementation (FS), PS+FS, clinic control (CC) and hospital control (CH) at discharge. PS included play sessions with children and parental counselling to mothers during fortnightly follow-up visit at community clinics, conducted by trained play leaders for 6 months. FS involved cereal-based supplements (150-300 kcal/day) for 3 months. All groups received medical care, micronutrient supplements and growth monitoring. We used Bayley scales, Home Observation for Measurement of Environment (HOME) inventory and a parenting questionnaire to assess child development, home stimulation and mothers' child-rearing practices, respectively. We assessed mothers' depressive symptoms using a modified version of Centre for Epidemiologic Studies Depression Scale at baseline and at 6 months post intervention. RESULTS: Maternal depressive symptoms were significantly lower in the CH group at baseline (P = 0.014). After 6 months of intervention there was no significant effect of intervention after adjusting for baseline scores and all possible confounders. Maternal depressive symptoms were higher among poorer (P = 0.06), older (P = 0.057) and less educated (P = 0.019) mothers, who were housewives (P = 0.053), and whose husbands had more unstable jobs (P = 0.058). At 6 months post intervention, children's cognitive (P = 0.045) and motor (P = 0.075) development, HOME (P = 0.012) and mother's parenting score (P = 0.057) were higher among mothers with lower depressive symptoms. CONCLUSION: The study did not show a significant effect of the intervention on the level of maternal depressive symptoms. Interventions with higher intensity and/or of longer duration focusing directly on maternal psychosocial functioning are probably needed to reduce maternal depressive symptoms.

Effects of a community-based approach of food and psychosocial stimulation on growth and development of severely malnourished children in Bangladesh: a randomised trial.

BACKGROUND/OBJECTIVE: Psychosocial stimulation (PS) and food supplementation (FS) improve development of malnourished children. This study evaluates the effects of a community-based approach of PS and FS on growth and development of severely malnourished children. SUBJECTS/METHODS: Severely underweight hospitalised children aged 6-24 months (n = 507) were randomly allocated on discharge to five groups: (i) PS, (ii) FS, (iii) PS+FS, (iv) clinic-control and (v) hospital-control. PS included play sessions and parental counselling on child development. This was done at each fortnightly follow-up visit, that is, every second week, for 6 months at community clinics. FS included distribution of cereal-based food packets (150-300 kcal/day) for 3 months. All groups received medical care, micronutrient supplementation, health-education and growth monitoring. Children's development was assessed using revised version of Bayley Scales of Infant Development at baseline and after 3 and 6 months of intervention. Anthropometry was measured using standard procedure. RESULTS: Comparing groups with any stimulation with those with no stimulation there was a significant effect of stimulation on children's mental development index (group*session interaction P = 0.037, effect size = 0.37 s.d.) and weight-for-age Z-score (group*session interaction P = 0.02, effect size=0.26 s.d.). Poor levels of development and nutritional status were sustained, however, due to their initial very severe malnutrition. There was no effect on motor development and linear growth. CONCLUSION: Children receiving any stimulation showed a significant benefit to mental development and growth in weight. More intensive intervention with longer duration is needed to correct their poor developmental levels and nutritional status.

FACTORS ASSOCIATED WITH INTERNALISING PROBLEMS IN ORPHANS AND THEIR CAREGIVERS IN RURAL MOZAMBIQUE.

OBJECTIVES: To compare internalising problems reported by orphans and their caregivers with that of non-orphans and their caregivers. DESIGN: Case control study. SETTING: Cahora-Bassa District of Tete, Mozambique SUBJECTS: Seventy-six maternal or double orphans (aged 10-14 years) and their caregivers were compared with seventy-four non-orphans and their caregivers living in the same neighbourhood. MAIN OUTCOME MEASURES: children were interviewed with a semi-structured questionnaire concerning their internalising problems, family structure, school attendance, daily experiences and perceived problems. The children's primary caregivers were also interviewed concerning their depressive symptoms, available social support, socio-economic conditions and perceived problems. RESULTS: Orphans lived in poorer households than non-orphans and reported more internalising symptoms and more economic and psychosocial disadvantages. Orphan caregivers were more depressed and had less social support than non-orphan caregivers. Child internalising symptoms were independently associated with bullying (B = 8.04, 95% CI: 0.24,15.85), perceived undeserved punishment (B = 11.98, 95% CI: S.98,17.98) and orphan status (B = 33.36, 95% CI: 26.67, 40.05). The effect of punishment was stronger for orphans than non-orphans. Frequency of hunger affected internalising symptoms only in orphans. Caregiver depression was independently associated with low social support (B = -0.35, 95% CI: -0.51, -0.18), few possessions (B = -2.10, 95% CI: -3.42, -0.79) an orphan status (B = 4.54, 95% CI: 3.30, 5.78) and possessions had a stronger effect in orphan caregivers. Quality of housing caused depression only in caregivers of orphans. CONCLUSION: Both orphans and their caregivers were more depressed than the non-orphans and their caregivers. They were exposed to more economic and psychosocial disadvantages and were more vulnerable to risks.

Effects of psychosocial stimulation on growth and development of severely malnourished children in a nutrition unit in Bangladesh.

BACKGROUND/OBJECTIVES: Young children with severe malnutrition usually have poor mental development. Psychosocial stimulation may reduce their cognitive deficit, but it is not usually provided. The aim of the study was to incorporate stimulation into the routine treatment of severely malnourished children in a nutrition unit and evaluate the impact on their growth and development. DESIGN: Time-lagged controlled study. SETTING: Nutritional Rehabilitation Unit (NRU) in ICDDR,B Dhaka Hospital. METHODS: Severely malnourished children, aged 6-24 months, admitted to the NRU were enrolled. All received standard nutritional care. A control group of 43 children was studied initially, followed by an intervention group of 54 children. The intervened mothers and children participated in daily group meetings and individual play sessions for 2 weeks in hospital and were visited at home for 6 months. Children's growth was measured and development assessed using the Bayley Scales of Infant Development. RESULTS: Twenty-seven children were lost to the study. In the remaining children, both groups had similar developmental scores and anthropometry initially. After 6 months, the intervention group had improved more than the controls did by a mean of 6.9 (P<0.001; 95% CI: 3.9, 10.0) mental and 3.1 (P=0.024; 95% CI: 0.4, 5.7) motor raw scores and a mean of 0.4 (P=0.029; 95% CI: 0.1, 0.8) weight-for-age z scores, controlling for background variables. CONCLUSION: Psychosocial stimulation integrated into treatment of severely malnourished children in hospital, followed by home visits for 6 months, was effective in improving children's growth and development and should be an integral part of their treatment.

Determinants of aggressive and prosocial behaviour among Jamaican schoolboys.

PURPOSE: This study examines risk factors for aggression among boys in Kingston, Jamaica. METHODS: One hundred and one aggressive and 101 prosocial schoolboys in grades 5-6 (mean age 11.7, SD 0.6 years) were selected by peer and teacher ratings from 10 schools in the capital city, Kingston, during 1998. They were given in-depth questionnaires, arithmetic, reading and verbal intelligence tests and their behaviour was rated. Their parents were also given a detailed questionnaire. RESULTS: The aggressive boys reported significantly more involvement in fights than the prosocial boys. They had lower scores on spelling/reading and verbal IQ, less ambitious aspirations and poorer quality school uniforms. They were not more likely to infer hostile intent in ambiguous situations but were more likely to respond with aggression. Aggressive boys came from poorer homes with more marijuana use, less parental affection or supervision and more family discord. They were less exposed to religious instruction, their parents had lower occupational levels and were more likely to be in common-law unions than married. They were more exposed to neighbourhood violence and were punished more often at home and at school. Logistic regression analyses were carried out to determine the independent risk factors for aggression. Exposure to neighbourhood violence, physical punishment at home and family discord were associated with increased risk; parents' being married, practising religion as a family and better school uniforms were associated with reduced risk. CONCLUSIONS: Although community violence was a serious problem, family characteristics were also important risk factors for aggressive behaviour.

Determinants of aggressive and prosocial behaviour among Jamaican schoolboys / Determinantes del comportamiento agresivo y prosocial entre los escolares Jamaicanos)

PURPOSE: This study examines risk factors for aggression among boys in Kingston, Jamaica. METHODS: One hundred and one aggressive and 101 prosocial schoolboys in grades 5-6 (mean age 11.7, SD 0.6 years) were selected by peer and teacher ratings from 10 schools in the capital city, Kingston, during 1998. They were given in-depth questionnaires, arithmetic, reading and verbal intelligence tests and their behaviour was rated. Their parents were also given a detailed questionnaire. RESULTS: The aggressive boys reported significantly more involvement in fights than the prosocial boys. They had lower scores on spelling/reading and verbal IQ, less ambitious aspirations and poorer quality school uniforms. They were not more likely to infer hostile intent in ambiguous situations but were more likely to respond with aggression. Aggressive boys came from poorer homes with more marijuana use, less parental affection or supervision and more family discord. They were less exposed to religious instruction, their parents had lower occupational levels and were more likely to be in common-law unions than married. They were more exposed to neighbourhood violence and were punished more often at home and at school. Logistic regression analyses were carried out to determine the independent risk factors for aggression. Exposure to neighbourhood violence, physical punishment at home and family discord were associated with increased risk; parents' being married, practising religion as a family and better school uniforms were associated with reduced risk. CONCLUSIONS: Although community violence was a serious problem, family characteristics were also important risk factors for aggressive behaviour.

Propósito: Este estudio examina los factores de riesgo que influyen en la agresión entre los niños en Kingston, Jamaica. Métodos: Ciento un escolares agresivos y 101 escolares prosociales en los grados 5­6 (edad promedio 11.7, desviación estándard 0.6 años) fueron seleccionados de acuerdo con las valoraciones de los pares y los maestros de 10 escuelas en la ciudad capital, Kingston, durante 1998. Se les aplicó cuestionarios exhaustivos, así como pruebas de aritmética y lectura, tests de inteligencia, y se clasificó su conducta. A sus padres también se les aplicó un cuestionario detallado. Resultados: Los niños agresivos reportaron una participación en peleas significativamente mayor que los niños prosociales. Asimismo, tuvieron puntuaciones más bajas en deletreo, lectura y coeficiente de inteligencia (C.I.) verbal, mostraron tener aspiraciones menos ambiciosas, y vestían uniformes más pobres. No estaban más inclinados a inferir intenciones hostiles en situaciones ambiguas, pero si más propensos a responder agresivamente. Los niños agresivos provenían de hogares más pobres, caracterizados por mayor consumo de marihuana, menos afecto o supervisión por parte de los padres, y más discordia en la familia. Estaban también menos expuestos a la instrucción religiosa, sus padres tenían bajo nivel ocupacional, y vivían en su mayor parte más en unión consensual que en matrimonio. Estaban más expuestos a la violencia del vecindario, y recibían castigos en la casa y la escuela con mayor frecuencia. Se llevaron a cabo análisis de regresión logística a fin de determinar los factores de riesgo de la agresión. La exposición a la violencia del vecindario, el castigo físico en el hogar, y la discordia familiar estaban asociados con el aumento del riesgo. En cambio, padres casados en matrimonio, la práctica de la religión como familia, y mejores uniformes escolares, estuvieron asociados con la reducción del riesgo. Conclusiones. Aunque la violencia comunitaria constituía un serio problema, las características de la familia fueron también importantes factores de riesgo en el comportamiento agresivo.

The effect of early stimulation on maternal depression: a cluster randomised controlled trial.

AIM: To determine the effect of early childhood stimulation with undernourished children and their mothers on maternal depression. METHODS: Mothers of 139 undernourished children (weight for age < or =-1.5 z-scores) aged 9-30 months were recruited from 18 government health centres in the parishes of Kingston, St Andrew, and St Catherine, Jamaica. They received weekly home visits by community health aides for one year. Mothers were shown play activities to do with their child using home made materials, and parenting issues were discussed. Frequency of maternal depressive symptoms was assessed by questionnaire. Child development was also measured. RESULTS: Mothers in the intervention group reported a significant reduction in the frequency of depressive symptoms (b = -0.98; 95% CI -1.53 to -0.41). The change was equivalent to 0.43 SD. The number of home visits achieved ranged from 5 to 48. Mothers receiving > or =40 visits and mothers receiving 25-39 visits benefited significantly from the intervention (b = -1.84, 95% CI -2.97 to -0.72, and b = -1.06, 95% CI -2.02 to -0.11, respectively) while mothers receiving <25 visits did not benefit. At follow up, maternal depression was significantly negatively correlated with children's developmental quotient for boys only. CONCLUSIONS: A home visiting intervention with mothers of undernourished children, with a primary aim of improving child development, had significant benefits for maternal depression. Higher levels of maternal depression were associated with poorer developmental levels for boys only.

Salivary cortisol and heart rate in stunted and nonstunted Nepalese school children.

OBJECTIVE: To test the hypothesis that stunted Nepalese children have an altered stress response system when compared with matched nonstunted children in response to a battery of psychological tests. DESIGN: Case-control study. SETTING: Poor urban areas of Kathmandu, Nepal. SUBJECTS: A total of 64 stunted (less than -2 s.d. height-for-age) children compared with 64 nonstunted (> -1s.d. height-for-age) schoolchildren between 8 and 10 y old matched for school and sex. METHODS: A psychological test session was administered, which included mental arithmetic and two tests of working memory. Salivary cortisol samples were obtained at five points during testing, and heart rate was measured during testing and also at baseline. Salivary cortisol samples were also obtained once early in the morning. Hemoglobin was assessed at the testing session, and extensive data were obtained on the social background of the children's families. RESULTS: Stunted Nepalese children showed a blunted physiologic response (salivary cortisol and heart rate) to psychological stressors (P<0.05) when compared with nonstunted children, but were not different from the nonstunted children in baseline measures, when controlling for social background. The two groups were not different in terms of social background. CONCLUSIONS: These findings suggest that childhood growth retardation may be associated with changes in physiological arousal, and that stunting could be associated with hyporesponsivity in response to psychological stress.

Factors associated with size and proportionality at birth in term Jamaican infants.

The objective of this study was to identify the factors associated with size and proportionality at birth in a cohort of term infants established to investigate their growth and development. One hundred and forty term low-birth-weight (birth-weight < 2,500 g) infants and 94 normal birth-weight infants (2,500- < 4,000 g) were recruited within 48 hours of birth at the main maternity hospital, Kingston, Jamaica. Birth anthropometry and gestational age were measured, and maternal information was obtained by interview and from hospital records. Controlling for gestational age, variables independently associated with birth-weight were rate of weight gain in the second half of pregnancy, maternal height, haemoglobin level < 9.5 microg/dL, time of first attendance in antenatal clinic, birth order, pre-eclampsia, and consumption of alcohol, with 33% of the variance in birth-weight explained. Birth length was associated only with maternal height and age, while measures of proportionality (ponderal index and head/length ratio) were associated with characteristics of the environment in late pregnancy, including rate of weight gain, weight in late pregnancy, and pre-eclampsia. The variation in maternal characteristics associated with size or proportionality at birth may reflect the times during gestation when different aspects of growth are most affected.

Mothers of undernourished Jamaican children have poorer psychosocial functioning and this is associated with stimulation provided in the home.

OBJECTIVES: To compare mothers of undernourished children with mothers of adequately nourished children on maternal depression, parenting self-esteem, social support and exposure to stressors and to determine if these variables are independently related to undernutrition and stimulation provided in the home after controlling for socio-economic status. DESIGN: A case control study. SETTING: Children and their mothers were recruited from 18 government health centres in the Kingston, St Andrew and St Catherine parishes of Jamaica. SUBJECTS: One hundred and thirty-nine mothers of undernourished children (WAZ< or =-1.5z scores) aged 9 - 30 months and 71 mothers of adequately nourished children (WAZ > -1z scores) matched for sex and age group were enrolled into the study. RESULTS: Mothers of undernourished children came from poorer homes but had similar social support to mothers of adequately nourished children. They were more depressed, had lower levels of parenting self-esteem (both P<0.01), reported higher levels of economic stress (P<0.001) and provided a less stimulating home environment (P<0.05). However, after controlling for social background variables there was no independent relationship between either psychosocial function or home stimulation and nutritional status. Undernutrition was found to be mainly explained by economic factors. The mothers' self-esteem was independently associated with the level of stimulation provided to the child. CONCLUSIONS: When caring for undernourished children attention should be paid to the psychosocial status of the mother as well as the physical condition of the child. SPONSORSHIP: Thrasher Research Fund; Campus Research and Publication Fund, UWI, Jamaica.

Early childhood stunting and later behaviour and school achievement.

BACKGROUND: Stunting in early childhood is common in developing countries and is associated with poorer cognition and school achievement in later childhood. The effect of stunting on children's behaviours is not as well established and is examined here. METHOD: Children who were stunted at age 9 to 24 months and had taken part in a 2-year intervention programme of psychosocial stimulation with or without nutritional supplementation were reexamined at age 11-12 years and compared with non-stunted children from the same neighbourhoods. Their school and home behaviours were assessed using the Rutter Teacher and Parent Scales and school achievement was measured using the Wide Range Achievement Test (WRAT) and the Suffolk Reading Scales. RESULTS: No significant intervention effects were found among the stunted groups. Thus data from the four intervention groups were aggregated for subsequent analyses, comparing all 116 stunted children with 80 non-stunted children. Controlling for social background variables, the stunted group had more conduct difficulties (p < .05) as rated by their parents. They also had significantly lower scores in arithmetic, spelling, word reading and reading comprehension than the non-stunted children (all p < .001). Conduct difficulties and hyperactivity were related to poorer school achievement. Controlling for the children's IQ, the stunted children's arithmetic scores remained significantly lower than those of the non-stunted children, but reading and spelling scores were not different. CONCLUSIONS: Previously stunted children had more conduct difficulties at home, regardless of their social background, than non-stunted children. Their educational attainment was also poorer than non-stunted children and these results are suggestive of a specific arithmetic difficulty. Children with behaviour problems performed less well at school.

Psychological well-being of orphans in Dar El Salaam, Tanzania.

UNLABELLED: Forty-one orphans whose fathers and/or mothers had died from AIDS, and were living in the poor suburbs of Dar Es Salaam, Tanzania, were compared with 41 matched non-orphans from the same neighbourhoods. The subjects were given an arithmetic test and a semi-structured questionnaire concerning any internalizing problems, their attendance at school and their experiences of punishment, reward and hunger. The scale of internalizing problems comprised 21 items adapted from the Rand Mental Health and Beck Depression Inventories concerning mood, pessimism, somatic symptoms, sense of failure, anxiety, positive affect and emotional ties. Most orphans lived with aunts and uncles. Compared with non-orphans, they were significantly less likely to be in school but those who did attend school had similar arithmetic scores. Significantly more orphans went to bed hungry. Orphans had markedly increased internalizing problems compared with non-orphans (p < 0.0001) and 34% reported they had contemplated suicide in the past year. Multiple regression analysis indicated that the independent predictors of internalizing problem scores were sex (females higher than males), going to bed hungry, no reward for good behaviour, not currently attending school, as well as being an orphan. CONCLUSION: The orphans not only had unmet basic needs, but also had markedly increased internalizing problems, thus their long-term mental health would be in jeopardy. There is an urgent need to expand and improve current intervention programmes not only to meet the basic needs but also to include psychosocial support, counselling services for the orphans, and training for their carers and teachers.

Randomized controlled trial of the effect of zinc supplementation on the mental development of Bangladeshi infants.

BACKGROUND: Zinc deficiency is thought to be common in young children in developing countries and some data suggest that it may detrimentally affect children's development. OBJECTIVE: Our goal was to assess the effect of zinc supplementation on the developmental levels and behavior of Bangladeshi infants. DESIGN: This was a randomized, double-blind, controlled trial conducted in Dhaka, Bangladesh. Three hundred one infants aged 1 mo were randomly assigned to receive either 5 mg elemental Zn or placebo daily for 5 mo, and subsequent growth and morbidity were observed. For the present study, developmental levels were assessed in a subsample of 212 infants at 7 and 13 mo of age with use of the Bayley Scales of Infant Development, and the infants' behavior during the tests was observed. The children's social backgrounds, weights, and lengths were also recorded. RESULTS: The children's nutritional status was generally poor. The zinc-treated group had slightly lower scores on the mental development index of the Bayley Scales than did the placebo group (beta = 3.7, SE = 1.3, P < 0.005). This effect remained significant when nutritional status and social background were controlled for. No other significant differences between groups were noted. CONCLUSIONS: The mental development index scores of the zinc-treated group were slightly but significantly lower than those of the placebo group. This finding may have been due to micronutrient imbalance. Caution should be exercised when supplementing undernourished infants with a single micronutrient.

The effects of birth weight and postnatal linear growth retardation on blood pressure at age 11-12 years.

STUDY OBJECTIVE: To determine the effects of birth weight and linear growth retardation (stunting) in early childhood on blood pressure at age 11-12 years. DESIGN: Prospective cohort study. SETTING: Kingston, Jamaica. PARTICIPANTS: 112 stunted children (height for age < -2 SD of the NCHS references) and 189 non-stunted children (height for age > -1 SD), identified at age 9-24 months by a survey of poor neighbourhoods in Kingston. MAIN RESULTS: Current weight was the strongest predictor of systolic blood pressure (beta= 4.90 mm Hg/SD weight 95%CI 3.97, 5.83). Birth weight predicted systolic blood pressure (beta = -1.28 mm Hg/SD change in birth weight, 95% CI -2.17, -0.38) after adjustment for current weight. There was a significant negative interaction between stunting in early childhood and current weight indicating a larger effect of increased current weight in children who experienced linear growth retardation in early childhood. There was no interaction between birth weight and current weight. The increase in blood pressure from age 7 to age 11-12 was greater in children with higher weight at age 11-12 and less in children with higher birth weight and weight at age 7. CONCLUSIONS: Birth weight predicted systolic blood pressure in Jamaican children aged 11-12. Postnatal growth retardation may potentiate the relation between current weight and blood pressure. Greater weight gain between ages 7 and 11 was associated with a greater increase in systolic blood pressure. The relation between growth and later blood pressure is complex and has prenatal and postnatal components.

Cognitive and motor functions of iodine-deficient but euthyroid children in Bangladesh do not benefit from iodized poppy seed oil (Lipiodol).

Iodine supplementation before pregnancy in iodine-deficient women prevents cretinism and neuromotor deficits in their offspring. It is unclear whether iodine supplementation benefits cognitive function in iodine-deficient school-aged children. We therefore conducted a double-blind, randomized, controlled trial of the effects of iodized poppy seed oil (Lipiodol) on cognitive and motor function and weight gain of iodine-deficient school children. The study was conducted with 305 children in grades 1 and 2 from 10 primary schools in two iodine-deficient areas in Bangladesh. The children were stratified by school and grade and randomly assigned to receive 400 mg of oral Lipiodol or a placebo. All children were given a battery of cognitive and motor function tests and had their weights, serum thyroxine (T4) and thyroid-stimulating hormone (TSH) and urinary iodine levels measured before and 4 mo after the intervention. On enrollment, both groups were moderately iodine deficient (median urinary iodine values: placebo group = 3.3 micromol/L, n = 148; iodine group = 3.1 micromol/L, n = 152; goiter prevalence in both groups >95%). However, their T4 and TSH levels were within the normal range. After 4 mo, there was a significant treatment effect on urinary iodine levels (P < 0.0001), but the levels of the treated group were still below normal (median = 7.9 micromol/L). No significant differences were found in T4 and TSH levels, weight gain, cognitive or motor function. The findings suggest that Lipiodol supplementation in moderately iodine-deficient children with normal T4 levels is unlikely to benefit their cognitive function. However, it remains possible that other iodine preparations may have benefits.

A review of studies on the effect of iron deficiency on cognitive development in children.

Studies on the effect of iron deficiency on children's cognition and behavior are selectively reviewed, looking for evidence of a causal relationship. Most correlational studies have found associations between iron-deficiency anemia and poor cognitive and motor development and behavioral problems. Longitudinal studies consistently indicate that children anemic in infancy continue to have poorer cognition, school achievement, and more behavior problems into middle childhood. However, the possible confounding effects of poor socioeconomic backgrounds prevent causal inferences from being made. In anemic children <2 y old, short-term trials of iron treatment have generally failed to benefit development. Most longer trials lacked randomized placebo groups and failed to produce benefits. Only one small randomized controlled trial (RCT) has shown clear benefits. It therefore remains uncertain whether the poor development of iron-deficient infants is due to poor social backgrounds or irreversible damage or is remediable with iron treatment. Similarly, the few preventive trials have had design problems or produced no or questionable benefits only. For children >2 y old, the evidence from RCT is reasonably convincing but not conclusive. RCT of iron treatment are warranted especially in younger children.

Poor nutrition is a serious problem in children with cerebral palsy in Palawan, the Philippines.

Children with cerebral palsy (CP) in developed countries have poor nutritional status; however there is little data from developing countries. In Palawan, in the Philippines, the nutritional status of 31 children with CP was compared to that of their siblings (n = 20) and a control group of neighbourhood children (n = 64), matched for age and sex. The children's weights, heights and armspans were measured. The heights of children with CP could not be measured and were estimated from their armspans using an equation relating height to armspan in siblings and controls. Haemoglobin levels of the study cases and siblings were measured. Siblings and controls had similar nutritional status. The children with CP had extremely poor nutritional status, and had significantly smaller weights for height, heights for age and weights for age than siblings or controls. Haemoglobin levels were not significantly different between the children with CP and their siblings. The nutritional status of children with quadriplegic CP was much poorer than that of similar children in the USA. The severity of malnutrition in children with CP is likely to be detrimental to their development, and a nutritional component should be incorporated into rehabilitation programmes. Also, there is a need to examine the nutritional status of children with CP in other developing countries.

Impact of asymptomatic malaria parasitaemia on cognitive function and school achievement of schoolchildren in the Yemen Republic.

Asymptomatic malaria parasitaemia is prevalent among schoolchildren in many countries. The relationship between asymptomatic parasitaemia and children's cognitive functions was examined in a case control study and then in a natural experiment. A group (n = 445) of asymptomatic parasitaemic boys were compared with a group of non-parasitaemic boys (n = 142) matched for grade and school on their performance on a battery of cognitive tests. Two weeks later the parasitaemic children were re-screened and 150 children of those who remained parasitaemic were matched for grade and school with 150 children who were no longer parasitaemic. These children were then re-tested and their cognitive function compared. Initially, after controlling for age, socio-economic background and nutritional status the parasitaemic children performed worse than the non-parasitaemic children in fine motor function tests. There was no difference in change in cognitive test scores between those who became non-parasitaemic and those who remained parasitaemic. However, children who initially had the highest parasite density improved the most in 2 fine motor tests and a picture memory test. We were unable to show a benefit from losing parasitaemia over a 2 week period, but it remains possible that parasitaemia may affect cognition and longer term trials should be conducted.

Early linear growth retardation and later blood pressure.

OBJECTIVE: To examine the effects of stunting in early childhood on blood pressure in later childhood. DESIGN: A cohort study. SETTING: Kingston, Jamaica. SUBJECTS: Seven to eight year old children, 120 stunted (height for age <-2 s.d. of the NCHS references) and 224 non-stunted (height for age >-1 s.d. of the NCHS references) at age 9-24 months. METHODS: Stunted and non-stunted children were identified at age 9-24 months by house to-house survey of poor neighbourhoods in Kingston, Jamaica. Blood pressure and anthropometry were measured at age 7-8 y. Birth weight was obtained from hospital records (73%) or maternal recall. RESULTS: The stunted children remained shorter and thinner than the non-stunted ones. In multiple regression analysis adjusting for size and pulse rate, the stunted children had higher systolic blood pressure (P<0.05). Birth weight was not a significant predictor of systolic blood pressure. CONCLUSION: Stunting in early childhood may increase the risk of elevated systolic blood pressure in later life. SPONSORSHIP: Nutricia Research Foundation, The Netherlands and the Commonwealth Caribbean Medical Research Council.