The role of care in nutrition programmes: current research and a research agenda.

The importance of cultural and behavioural factors in children's nutrition, particularly with regard to feeding, has been recognized only recently. The combination of evidence regarding the importance of caregiving behaviour for good nutrition, and improved strategies for measuring behaviour have led to a renewed interest in care. The UNICEF conceptual framework suggests that care, in addition to food security and health care services, are critical for children's survival, growth and development. The present paper focuses on the care practice of complementary feeding, specifically behavioural factors such as parental interaction patterns, feeding style and adaptation of feeding to the child's motor abilities (self-feeding or feeding by others). Three kinds of feeding styles (Birch & Fisher, 1995) are identified: controlling; laissez-faire; responsive. Probable effects of each feeding style on nutrient intake are described. A number of studies of feeding behaviour have suggested that the laissez-faire style is most frequently observed among families and communities with a higher prevalence of malnourished children. Nutrition interventions that have been able to show significant effects on outcomes, such as the Hearth Model in Vietnam (Sternin et al. 1997), have usually incorporated behavioural components in their intervention. At this time, there have been no tests of the efficacy of behavioural interventions to improve feeding practices. Research is needed to understand behavioural factors in complementary feeding, and to identify and test intervention strategies designed to improve nutrient intake of young children. Finally, the paper concludes with a discussion of how nutrition programmes might change if care were incorporated.

Care for nutrition and development.

Optimal growth and development depend not only on food quality and availability, on access to health care services and a healthy environment but also on the care provided to the child especially during the first few years of life. Care refers to the actions and practices of caregivers on a day to day basis that translate food, heakh care, and water and sanitation supplies into good growth and development of children. It includes behaviours such as feeding, sanitation and hygiene, home health practices, preparing food for children, and providing psychosocial support for development. Families also are responsible for providing care for girls in the family and women. Care requires resources--both skills and capabilities, as well as economic resources. Some resources are easily recognised, such as education of the caregiver, but others are less often seen, including time of the caregiver, motivation of caregiver and male family members, organisational resources such as child care centres, and the caregiver's ability to influence decisions about child care. It must be noted that the poorer the family, the more risks for children in the environment. Therefore, the poorer the environment, the more important a role care has in children's survival, growth and development. Implications for health care providers include assessing the care practices in the home, and resources for care when making recommendations; supporting positive practices already being performed in order to empower the caregiver; checking the understanding and recall of the caregiver; and finally, recognising that all children, regardless of gender, ethnicity, case, economic level, etc, have a right to good nutrition and health care in order to develop to their fullest potential under the Convention for the Rights of the Child, acceded to by India in 1992.

Effects of discontinuing coffee intake on iron deficient Guatemalan toddlers' cognitive development and sleep.

Coffee is commonly given daily to toddlers in Guatemala. Possible negative effects of coffee ingestion on cognitive development and sleep patterns were assessed in 132 children 12-24 months of age who had received coffee for > 2 months and were iron deficient on at least one indicator. Children were stratified by initial hemoglobin (A= anemic, Hgb < 10.5 g/dl; NA = 'non-anemic', Hgb > or = 10.5 g/dl) and were randomly assigned to an experimental group (S = substitute consisting of sugar and coloring), and a control group (C = continuation of coffee) (42 C-NA; 53 S-NA; 18 C-A; and 19 S-A). Anemic children were provided Fe supplements for 2-3 months. Compliance was assessed every 2 weeks. After 5 months, testers masked to treatment group and anemia evaluated children with the Bayley Scales of Infant Development II in a central location. Scores were the Mental Development Index (MDI), the Psychomotor Development Index (PDI), and scales from the Behavior Rating Scale (BRS). The child's sleep in the previous 24 h was assessed with a set of standardized sleep questions to the care giver on the first visit and every 2 weeks thereafter. No significant effects of treatment on test scores or BRS ratings were found. In the 24 h period reported on at the final visit, children in the Substitute group slept more during the night and overall (night plus naps) than children in the Coffee group, a difference not found at the first visit. No differences were found in sleep difficulty or number of times waking at night. Women's reported coffee intake per day during pregnancy was associated with lower BRS ratings, even after controlling for SES and child age. The effects of postnatal coffee ingestion in Guatemala were seen for sleep duration, but not for cognitive development. Prenatal coffee ingestion was negatively associated with Behavior Rating Scales and should be investigated further.

Maternal employment, child care, and nutritional status of 12-18-month-old children in Managua, Nicaragua.

Relationships among women's employment, child care strategies, and nutritional status of children 12-18 months of age were examined in 80 Nicaraguan households sampled by randomized block design in 10 low income urban communities. Multiple regression analyses showed that children of employed mothers (56%) fared better in weight/height than those whose mothers were not employed, with and without controlling for socioeconomic status and maternal education, paternal financial support, child care adequacy, and sex and age of the child. Children with inadequate alternate child care (care by a preteen or care at the work place) had lower height for age, even controlling for the same variables and for maternal employment. Differences in 10 caregiving behaviors between families as a function of work status of the mother and adequacy of child care were examined. In families with working mothers, caregivers were less likely to be observed washing their hands, suggesting that the positive associations of work for earnings might be due to income rather than improved care. Inadequate care was associated with less food variety, less use of health care, and marginally less hand-washing. Inadequate child care, which tends to be associated with informal work, nuclear families and poverty, should be a concern for child welfare.

The role of men in families: achieving gender equity and supporting children.

PIP: Fathers and men in families are one of the most important resources for children's well-being. UNICEF, the Ford Foundation, Save the Children, other nongovernmental organizations, and resolutions from the 1994 International Conference on Population and Development have all recommended efforts to involve men in reproductive health programs. However, despite this interest and recommendations, social service and health programs, as well as development interventions, continue to target mothers and children, ignoring the major role of men in the lives of children and families. Most development interventions focusing upon family well-being have stressed the importance of the mother/child relationship, even in societies in which the father controls decisions about the household and family welfare. The author surveys program initiatives, conferences, research, and publications concerned with the role of men in the family.^ieng

Child development: vulnerability and resilience.

Many of the challenges facing children now are a function of changing times, including increase in urbanization, political violence, changing family forms, and in some areas decreased supplies of adequate food. This review focuses particularly on those changes in which children are the victims and which induce new threats for them, rather than on problems such as child disability or mental illness. The outcome variables of interest in this paper are dimensions of children's psychosocial development, including cognitive development, psychological adjustment and aggression, whereas the companion paper in this issue (Caldwell P., Child survival: vulnerability and resilience in adversity in the European past and the contemporary Third World, Soc. Sci. Med.) [1] focuses on physical aspects of children's development. The risks that are hurdles in the process of development of a young child begin from conception and carry on into later life. To address them all would be impossible; thus, in order to do justice to the issues at hand, we have chosen those risks that, in our view, are important in a child's psychosocial development in developing countries. This paper will thus provide a discussion of the concepts of risk and resilience, then apply these concepts to the analysis of three examples of risk faced by children today: nutritional threats (e.g. malnutrition due to decline in breastfeeding); family dynamics and types of family forms (e.g. child fostering and non-traditional families); and experiences of violence (domestic or political). In each case, the same four questions will be addressed: what are the consequences of the risk factor for children, what are the etiologies and conditions of risk, are there any children who seem to cope with the risk factor successfully and what are some of the protective factors, and what interventions or programs would help support these children?

Active feeding behavior compensates for low interest in food among young Nicaraguan children.

The association of caregivers' feeding behavior with young children's anthropometric status was examined in 80 poor urban families from Nicaragua. Caregiver and child behaviors observed during eating were recorded for midday meals, snacks and bottle feeds. Two kinds of scales were constructed. The Active Feeding Scale measured the caregiver's attempts to encourage or promote the child's food ingestion through behaviors such as verbal encouragement, threatening, offering more food or demonstrating eating. The Child Demand Scale measured the child's interest and enthusiasm for food. Results suggested the following: 1) there were significant differences in caregiver encouragement of feeding by meal type (midday meal, snack or bottle-feed); 2) mothers were significantly more likely to encourage eating than were other caregivers; and 3) active feeding was not associated with child anthropometric status but often appeared to be associated with child disinterest in the meal. It is suggested that active feeding may be used to compensate for child disinterest in food rather than to enhance the child's growth and developmental trajectory. The importance of lack of child interest in food, probably related to poor appetite, needs to be recognized and incorporated into nutrition education programs.

Nutrition in early life and the fulfillment of intellectual potential.

The effects of early supplementary feeding on cognition are investigated using data collected during two periods in four Guatemalan villages. The first was the Institute of Nutrition of Central America and Panama (INCAP) longitudinal study from 1969 to 1977 and the second was a cross-sectional follow-up of former participants carried out in 1988-1989. The principal objective of these studies was to assess the differential effect of two dietary supplements, Atole containing 163 kcal/682 kJ and 11.5 g protein per cup or 180 mL and Fresco containing 59 kcal/247 kJ and 0 g protein per cup, that were given to mothers, infants and young children. Performance was assessed on a battery of psychoeducational and information processing tests that were administered during adolescence. Consistent differences between groups were observed on psychoeducational tests. Subjects receiving Atole scored significantly higher on tests of knowledge, numeracy, reading and vocabulary than those given Fresco. Atole ingestion also was associated with faster reaction time in information processing tasks. In addition, there were significant interactions between type of dietary supplement and socioeconomic status (SES) of subjects. In Atole villages, there were no differences in performance between subjects in the lowest and highest SES categories. On the other hand, performance in Fresco villages was best in the highest compared with the lowest SES group. After close scrutiny of alternative hypotheses, it is concluded that dietary changes produced by supplementation provide the strongest explanation for the test performance differences observed in the follow-up between subjects exposed to Atole and those exposed to Fresco supplementation.

PIP: A longitudinal study conducted during 1969-77 by the Institute of Nutrition of Central America and a cross-sectional follow-up of former participants carried out during 1988-89 investigated the effects of early supplementary feeding. The objective of these two studies was to assess the differential effect of two dietary supplements--Atole, containing 163 kcal/683 kJ and 11.5 g protein per cup or 180 ml, and Fresco, containing 59 kcal/247 kJ and 0 g protein per cup--on cognition. The dietary supplements were given to mothers, infants, and young children. Performance was assessed on a battery of psychoeducational and information processing tests that were administered during adolescence. Consistent differences between groups were observed on psychoeducational tests. Findings revealed that subjects receiving Atole scored significantly higher on tests of knowledge, numeracy, reading, and vocabulary than those given with Fresco. Atole ingestion also was associated with faster reaction time in information processing tasks. In addition, there were significant interactions between type of dietary supplements and socioeconomic status (SES) of subjects. In Atole villages, there were no significant differences in performance between subjects in the lowest and highest SES categories. On the other hand, performance in Fresco villages was best in the highest compared with the lowest SES group.

Influences of mothers' and fathers' income on children's nutritional status in Guatemala.

The relative effects of fathers' and mothers' income on children's nutritional status were examined with a sample of 294 peri-urban Guatemalan children aged 8-47 months. Whether or not incomes tended to be pooled, and the relation of income earning to decision-making about purchases were examined. Four measures of income were constructed for both mother and father: total income, contribution to the household food budget, percentage of her/his income contributed to the household food budget, and a percentage of total family income earned by that person. In the majority of households, women did not report pooling their incomes. Women who earned a higher proportion of the family income had significantly more control over decision-making in all areas except food purchases, which were already primarily women's decisions. Relationships of income measures with children's nutritional status were examined with multiple linear regression analyses controlling for potentially confounding variables. For mothers, the percentage of the total family income they earned was most highly associated with children's nutritional status, suggesting that income control by mothers may have benefits for children. For fathers, the percentage of their income they contributed to the household food budget was most highly associated with children's nutritional status, suggesting that father investment or attitude toward children has important benefits for children.

Intra-household food distribution among Guatemalan families in a supplementary feeding program: behavior patterns.

The present study investigated how food is distributed to various family members differing in age, sex, earning status, family role, and status as target child in families enrolled in supplementary feeding programs in urban Guatemala. Two patterns to explain intra-household food distribution patterns were hypothesized: a Contributions Rule, that individuals considered in the culture to have higher economic value would receive a higher percentage of the family's food; and a Needs Rule, in which those considered to have greater need (but not contribution) would receive a higher percentage of the family's food. The results with 45 families (230 individuals) suggested that the Contribution Rule was a better predictor of food distribution patterns in this setting than the Needs Rule. Specifically, male heads of households received a relatively higher proportion of the family's proteins, and the female heads of households received a relatively higher proportion of the family's calories, given their nutritional requirements, than other family members. There was no evidence that mothers were giving the child targeted as undernourished by the health center any more food than any other similar-aged child.

Early supplementary feeding and cognition: effects over two decades.

The study reported in this Monograph of the effects of early supplementary feeding on cognition included two data collection periods: a longitudinal investigation spanning the years 1969-1977 and a cross-sectional follow-up carried out in 1988-1989. The study was conducted in four rural villages in Guatemala and compared the differential effects of exposure in childhood (0-7 years) to an Atole supplement (11.5 g of protein; 163 kcal) or a Fresco supplement (59 kcal) on performance on a battery of psychoeducational and information-processing tests in adolescence and young adulthood (11-24 years). In this report, particular attention is given to a cohort of subjects who were exposed to the supplement prenatally and during at least the first 2 years of postnatal life. Data on this subsample are contrasted with those on a cohort of subjects who received the supplement only after 24 months of life. The Monograph also reports results from an analysis of the supplementation effects in infancy and early childhood. Consistent differences between groups on the psychoeducational tests were observed. Adolescents from Atole villages scored significantly higher on tests of knowledge, numeracy, reading, and vocabulary than Fresco subjects. Atole was also associated with a faster reaction time in information-processing tasks. Significant interactions helped identify two groups who benefited more from the Atole treatment: those at the lowest levels of socioeconomic status and those who attained the highest levels of primary schooling. The consistent differences in test performance established in the follow-up assessment contrast sharply with the few and less pronounced between-group differences observed in the infancy and preschool periods. After close scrutiny of alternative hypotheses, it is concluded that nutritional differences provide the strongest explanation for the test performance differences observed in the follow-up between the subjects exposed to the Atole and those exposed to the Fresco supplement.

Maternal work and child-care strategies in peri-urban Guatemala: nutritional effects.

Associations of 293 mothers' work for earnings and child-care arrangements with the anthropometric status of their children were examined in urban Guatemala. It was hypothesized that during the period of life in which growth often falters (8 through 35 months), maternal employment could be beneficial for children. Informal workers tended to be poorer, less educated, and have more undernourished children than formal workers or nonworkers. When poverty and mother's education were controlled for, no effects of maternal employment on children's anthropometric growth patterns were seen. However, the percent of the family income the mother earned was positively associated with all anthropometric indicators, controlling for confounds. Children taken care of by preteen siblings had significantly lower weight for height than those in other situations, even controlling for SES and maternal employment status. These effects were not found in a 36-48-month-old sample.

PIP: A child development researchers analyzed data on 239 8-35 month old children living in 2 villages 20 km from Guatemala City, Guatemala to determine the effects of maternal work and child care arrangements on children's nutritional status. Women who worked flexible hours and had no defined job skills (informal workers) were more likely to be poor (p.01), less educated (p.0001), and have undernourished children (p.02 for height for age and p.01 for weight for age) than those women who either owned a business, had a trade, or worked in a store or factory (formal workers). Yet informal work was statistically related to those socioeconomic factors than jeopardize adequate growth of children. When the researcher controlled for poverty and maternal education, mother's work did not affect growth, however. This suggested that mother's work may have a positive effect on growth because if mothers did not work, the children may have actually experienced even poorer nutritional status. The data showed the arduous circumstances informal workers encounter, their poverty, and inadequate income for their labor. The children of full-time workers had a somewhat better weight for height status than nonworkers. Percent of family income earned by the mother had a significant effect on all anthropometric indicators (p.01 for height for age and weight for age; p.05 for weight for height). In both the 1-way analysis of variance and the same analysis controlling for socioeconomic status and mother's work, children cared for by a 13-year old sibling had a considerably lower weight for height than those cared for by nonworking mothers (p.008 and p.01 respectively). None of the effects existed in the 36-48 month old children in these villages.

Prenatal and postnatal anxiety in Mexican women giving birth in Los Angeles.

Examined psychosocial factors related to prenatal and postnatal anxiety in 291 primiparous Mexican women giving birth in Los Angeles. Characteristics of health care providers preferred by more anxious and less anxious women were also assessed. Higher prenatal anxiety was associated with less desire for an active role during labor, lower assertiveness, higher pain expectation at delivery, lack of support from family members other than the husband, and preferences for health care providers who are female and Latino. All groups of women preferred health care providers who provided good medical explanations and who were knowledgeable, friendly, and sympathetic. Postnatal anxiety was significantly lower than prenatal anxiety. Negative attitudes toward the baby and number of complications during labor and delivery, however, were related to postnatal anxiety adjusted for prenatal anxiety.

[Household food distribution behavior in periurban communities of Guatemala: lessons for food distribution programs]. / Conductas de distribución intra-hogareña de alimentos en comunidades periurbanas de Guatemala: lecciones para los programas de distribución de alimentos.

Do mothers of undernourished children recognize their offspring's needs? How do they feed these target children compared to other households members when food supplements are available? Which cultural principles of intra-household food distribution are associated with feeding behavior? How do household members perceive and use food supplements that are donated for undernourished target children? Answers were sought in a dietary-ethnographic study of 45 households receiving supplements for a low-weight child between one and five years, of age in two periurban low-income communities of the City of Guatemala. The central hypothesis was that we would find four cultural principles of food distribution: contributions, need, equity, and demand. The dietary survey combined direct measure and recall techniques and was done twice for all 230 individuals conforming these households. Ethnographic interviews were carried out with mothers of all target children. T-tests determined the relation between food distribution behavior and cultural rules. Findings revealed that the cultural principles of contributions, needs, and demand are present, but instead of the equity principle, we found one of equality. In the great majority of the feeding events observed, the child's mother prepares and distributes the food. The target child does not receive preferential treatment in the intra-household distribution of food supplements and other foodstuffs. Donated milk is destined principally for the children in the household; all other supplements are distributed among all members. Adult males are favored in the distribution of kcal at regular mealtimes. Children are favored in the distribution of kcal when total daily consumption is calculated. There are significant associations between the expressions of the cultural principle favoring equal distribution and that of contribution which favors adult men, and actual food distribution behavior. These principles seem to operate at formal meal events only. It was found that feeding behavior between meals (snacks, nibbling, etc.) is not subject to these salient principles and tends to compensate those household members who are not given preferential treatment in food distribution at formal mealtimes.

Factors affecting breastfeeding among women of Mexican origin or descent in Los Angeles.

Data on breastfeeding intentions and behavior were collected in prenatal and postpartum interviews as part of a study on first birth among 518 women of Mexican origin or descent in two Los Angeles hospitals. The prenatal intentions of 82 per cent of the women to breastfeed were maintained postpartum in one hospital but dropped sharply in the other. A greater number of hours a day with the baby in the hospital and earlier initiation of breastfeeding were associated with the hospital where prenatal breastfeeding intentions were more likely to be carried out. The intention to work postpartum was associated both with the decision not to breastfeed at all and with shorter intended duration of breastfeeding.

Sex differences in attitudes towards newborn infants among women of Mexican origin.

PIP: This paper analyzes a data set on women of Mexican origin delivering in Los Angeles hospitals, in order to examine whether Mexican women's attitudes toward their 1st-born infants are influenced by the sex of the child, either alone or in combination with other factors, such as the difficulty of labor and delivery or the woman's social support system. The authors' hypothesize that the mother's attitude toward the 1st child will be determined primarily by factors other than the child's sex, since there is evidence to suggest equal sex preference among women in Latin culture. They predict that the most negative attitudes would be expressed in the case of an unplanned pregnancy, of a child being born into an unstable family or with physical abnormalities. The women described in this paper are all from the Mestizo, or Hispanicized peoples from Mexico. The analyses are based on interviews with a sample of 518 low risk women. Data on the medical course of their labor and delivery was also collected from their medical charts. The operationalization and measurement of each predictive variable are explained. Sex differences in women's evaluations of their children were examined with Chi-Square analyses. As expected, almost no differences on any attitude measure were found. In general the mothers were very pleased with their infants, whether male or female, although there is a suggestion that if they were disappointed, they were more likely to be displeased with a female infant than with a male. Regression analyses, more sensitive for picking up sex differences than the simple Chi-Square, were performed to determine which of the predictive variables were most related to the mother's attitude. Results show that sex was not a predictive variable. Contrary to what was predicted, whether or not the baby was planned, appeared to be relatively unimportant in the mother's attitude toward her child. A 2nd surprising finding was that the woman's experience of birth was unrelated to her evaluation of her child. The social support system had a significant impact on the mother's evaluation of her child. For both boys and girls, social support from the baby's father was associated with a positive attitude toward infants. Women were significantly more negative toward their infants if they had a poor relationship with the baby's father. Finally, the more acculturated women expressed less positive attitudes toward their newborns; this relationship was slightly stronger for girls than boys.^ieng

The relationship between physical growth and infant behavioral development in rural Guatemala.

The present study investigated the relationship between a number of anthropometric indices and behavioral development during the first 2 years of life in rural Guatemala. Length and weight were the indices most strongly correlated with behavioral development. If the effect of the infant's length and weight was statistically controlled for, none of the other anthropometric variables explained a significant proportion of the variance in behavioral development. Controlling the length (or weight) assessed at the same age as the behavioral assessment, length (or weight) for younger ages was not significantly correlated with behavioral development. Changes in length or weight over time correlated with changes in behavioral performance. We were unable to explain the association between physical growth and behavioral development by a number of variables including gestational age, nutrient intake, prevalence of disease, and familial characteristics.

PIP: This study investigates the relationship between a number of anthropometric indices and behavioral development during the first 2 years of life in rural Guatemala. Length and weight are the indices most strongly correlated with behavioral development. If the effect on the infant's length and weight are statistically controlled for, none of the other anthropometric variables explain a significant proportion of the variance in behavioral development. Controlling for length (or weight) assessed at the same age as the behavioral assessment, length (or weight) for younger ages is not significantly correlated with behavioral development. Changes in length or weight over time are correlated with changes in behavioral performance. The authors are unable to explain the association between physical growth and behavioral developemnt by a number of variables including gestational age, nutrient intake, prevalence of disease, an familial characterisitcs.

Effects of maternal nutrition on fetal growth and infant development.

The results of a food supplementation study conducted in four chronically malnourished rural villages in Guatemala were analyzed to determine possible effects on the study children's early mental and physical development. One of two food supplements, atole and fresco, were given to pregnant and lactating mothers and the infants born to them up to three years of age. The level of supplement received was noted and the subsequent course of the children's development observed. Food supplementation of pregnant mothers was found to correlate with higher weights of their babies at birth. No other major maternal variables--home diet, body height and/or weight, morbidity, obstetric characteristics, or socioeconomic status--could account for this association. At 36 months of age the children who had received a large amount of food supplementation showed a far lower prevalence of growth retardation than did those who received smaller quantities. Again, this correlation could not be attributed to any other major maternal variables. In regard to mental development, food supplementation was found to correlate with better performance in psychological tests beginning at six months of age. At 36 months the correlations were significant in five different tests. The results of this analysis have wide-ranging implications for public health. Given the recognized association between low birthweight and infant mortality, they point especially to the importance of maternal nutrition during pregnancy in programs aimed at reducing this serious problem.