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Book review

Nutrition and development of children from poor rural areas nutrición y desarrollo infantil

Nutrition and Development of Children from Poor Rural Areas: Proyecto Puebla-Tezonteopan. Adolfo Chávez and Celia Martínez. División de Nutrición, Instituto Nacional de Nutrición, Mexico City, Mexico, 1978. 85 pp. (unpaginated), mimeographed.

Nutrición y Desarrollo Infantil. Adolfo Chávez and Celia Martinez. Nueva Editorial Interamericana, Mexico City, Mexico, 1979. xx + 148 pp., subject and name index.

Many earnest people, especially university students, impressed and oppressed by the stark reality and the awesome magnitude of malnutrition in the developing countries, are asking: "Why research? Do we not know all we need to know to wage a successful war against hunger? Will not any current and future research simply duplicate what has already been done?" And, importantly: "Is it not unethical to waste resources on research?"

People with such doubts, as well as a broad spectrum of professional personnel, would do well to familiarize themselves with the work of Adolfo Chávez and Celia Martinez and their collaborators in the "Puebla Project." These Mexican investigators have provided a large amount of novel, detailed, and important information on a number of practical issues, such as the decrease over time in the availability of mother's milk while the nutritional needs of the growing child are increasing. Concretely, in about half of the mother-child dyads studied by Chávez and Martínez, the daily production of breast milk reached its peak at 8 weeks; in the other half, at 24 weeks. The differences were related to the mother's parity and nutritional status. Failure to provide adequate supplementary food for the infant when needed spells malnutrition.

While chronically inadequate food intake affects many aspects of the human organism (metabolic, morphological, and functional), this complex pattern is usually fractured in research reports published in scientific journals. Often the individual papers are published in different journals, in accord with the scientific disciplines that deal with a particular set of variables. Even when it is feasible to publish a series of papers in a single journal-as was the case for the Puebla study, the results of which appeared in Nutrition Reports International between 1971 and 1979 -there is much to be said for presentation of the total picture in a monograph. This gives an opportunity to present the "philosophy"-the rationale and approach- of the investigators in sufficient detail, to provide a compact summary of the results, and to point out the practical implications of the findings.

TABLE 1. Contents of the Spanish and English Versions

*Dates in parentheses indicate the year in which the papers appeared in Nutrition Reports International.

I have reviewed Nutrition and Development of Children from Poor Rural Areas-a mimeographed collection of the papers as they originally appeared in English, with a brief introduction-in detail elsewhere, with special reference to the impact of undernutrition on behaviour. Here we shall give attention primarily to the Spanish edition, Nutrición, y Desarrollo Infantil, in which the materials have been supplemented and reworked into a systematic monograph.

The body of the Spanish monograph deals in seven chapters (chapters 2-8; see table 1) with the topics examined in the papers presented earlier in English. An added "head" consists of a prologue by Rafael Ramos-Galván, an introduction by the authors, and a description of the setting in which the study was done. The "tail" summarizes the findings and sets down their practical implications. In addition to the references for individual chapters, the bibliography contains a section in which journal articles and presentations made at conferences, congresses, and symposia are listed, together with five student theses concerned with breast milk and three monographs on lactation, the quality of life of peasant women, and the hygienic conditions in a poor Mexican village.

IMPLICATIONS OF THE FINDINGS FOR CORRECTIVE ACTION

While the study yielded substantial basic data, the fundamental aim of the project was to obtain information relevant to the mitigation and prevention of sub-clinical chronic malnutrition of infants and children. Appropriately, the monograph lists, in the order of perceived priority, recommended remedial actions. These are relevant not only for poor rural areas of Mexico but for their counterparts in many other parts of the world as well. The list of recommendations is as follows:

1. Initiate early the supplementary feeding of children born into poverty. Paradoxically, in terms of nutritional status and resistance to disease, such a child is biologically at its best in the very early phase of infancy. The child is still protected by maternal antibodies and has a good appetite. While early supplementary feeding is an effective antidote to creeping malnutrition, it does not represent a heavy drain on the family budget. Fruit juices and pureed fruit are recommended for use in early supplementation. Clearly, this should be a supplement to, not a replacement of, breast-feeding.

2. Give the infant enough food, until it reaches the point of satiety. The child is threatened by caloric insufficiency. Consequently, in case of dire need, even sugar or maize porridge will do. The digestive capacity of the infant is greater than we usually think it is, provided the food is mashed, strained, and freshly cooked. Ideally, the food should be prepared in a sanitary manner, but the point need not be stressed excessively, since the child lives in an environment that is heavily contaminated with pathogens.

3. Improve the nutrition of pregnant women. There are several cogent reasons why this point is not listed as the first priority: (i) it is easier to convince mothers that they should give more food to their children than that they should eat more food themselves; (ii) the procedure would be more expensive, since the mother would require a qualitatively better diet.

4. Improve the mother's nutrition during breast-feeding. While it is true that, in terms of a cost-benefit analysis, this is not the most efficient procedure-more food is required than when it is given to the child directly - the authors remind us that we have to consider the welfare not only of the child but of the mother as well.

5. Watch the child's physical development, using body weight as en indicator. This will identify the mothers with insufficient breast milk, a phenomenon more frequent in a poor environment than we commonly think. If a mother is unable to increase her milk production above the initial level (and no supplementary food is given), the child is certain to develop lethal malnutrition.

6. Bring the child's body weight to eight kilograms by eight months. This is a simple, rough guide. In a less dramatic form, the recommendation would read, "Bring the weight up to eight kilogram as rapidly as is feasible." This does not call for a specific, separate action but rather represents a goal towards which all of the first five recommended actions must contribute (birth weight of at least three kilograms, adequate supply of breast milk, early and adequate provision of supplementary food, correction of failing growth).

Three additional recommendations are not nutritional in nature, but are of crucial importance:

1. Endeavour to prevent infectious diseases and thus protect the child against disturbances of metabolism and against anorexia.

2. Space the birth of children properly. The study has shown that it is undesirable to have the mother become pregnant while she is breast-feeding a child. The milk supply is reduced and the child is likely to be weaned abruptly. The poorly nourished mother needs time to recover from one pregnancy before she starts another one.

3. Utilize education more effectively as a weapon in the struggle against malnutrition. In underdeveloped countries much can be achieved in this way, at a low cost, provided the educational effort is directed to nutritional issues of high priority, with awareness of the central importance of the mother-child dyed in the child's physical and mental development.

While the recommendations on the whole are sound, not all of the details may find universal acceptance among nutritionists and the members of related professions in the developing countries. Some critics will point to what may appear as internal inconsistencies, especially in regard to the concern (or lack of it) with infection Furthermore, other critics will insist that additional more far-reaching steps, including economic measures and a drastic reduction of population growth, need to be taken if we are to cope effectively with endemic, chronic malnutrition.

Yet if the core of the recommendations is put into practice and some of the details stimulate lively dialogue and research bearing on controversial issues, the study will have made a significant contribution.

Josef Brozek
Resident Co-ordinator
UNU World Hunger Programme
Massachusetts Institute of Technology
Cambridge, Mass., USA

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