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While the study of maternal-child feeding interactions relating to nutritional outcome has been limited, research linking mother-infant relations to psychological health and child intelligence is vast, heterogeneous, and spanned by many levels of analytic re solution (Hopkins and Kalverboer, 1983). This research has been both extensive (large sample) and intensive (small sample) and can be classified into unidirectional studies, looking at influences operating from mother to infant (M-l), infant to mother (I-M) or bidirectional (both ways). The recent trend is towards intensive fine-grained (micro) analyses investigating interactional processes. In both non-nutritional and the few existing nutrition studies, the inborn characteristics of children are increasingly recognized as contributing to the nature and quality of the mother-child relationship (Hopkins and Kalverboer, 1983; Pollitt and Wirtz, 1981). This relationship may, in turn, have an influence on the expression of the child's temperament.
Fig 7. Conceptual framework of factors influencing positive deviance and of programme types.
Lists of Interactions Related to Growth
Four tabular lists are provided below in sufficient detail as not to require a parallel narrative explanation. They are divided into mother-to-infant and infant-to-mother
general non-feeding interactions; and mother-to-infant and infant-to-mother feeding specific interactions. For simplicity of presentation, bidirectional interactions are put on both M-I and lM lists. A few variables linked to nutritional status through core relations with a third variable have been included and are so labelled. The reader should be aware that major methodological problems make it difficult to generalize from the findings of many of the studies reported. These difficulties include:
The reader will also note that the number and types of interactions linked to infant and youngchild growth are very extensive. Seen together they appear to encompass almost all aspects of mothering. The question inevitably arises: how is it possible to get a handle on these many interactions and categorize them in a way that permits their incorporation in health-education activities. The discussion that follows the set of lists will address these questions.
The list provided below refers to M-l and I-M non-feeding and feeding interactions shown in the literature as being associated with better nutritional status.
M-1 Non-feeding Interactions Linked to Growth in Infancy and Early Child hood
I-M Non-feeding Interactions Linked to Growth in Infancy and Early Childhood
M-l Feeding Interaction Linked to Growth in Infancy and Early Childhood
I-M Feeding Interactions Linked to Growth in Infancy and Early Childhood
The Importance of Bonding
Mother-child interaction during the first four hours following birth may have a particular beneficial effect by bonding the mother to her infant. Some evidence indicates that if the infant is put immediately to the breast and if the mother and baby have close physical contact at this time, the quality of all the mother's later interactions with the baby will be improved. The direction of this effect appears to be M-I. Both common sense (entire populations of mother/infant pairs do pretty well without this experience) and the literature make it evident that neo-natal bonding is not critical except perhaps for some mothers who are at a high risk of forming poor relationships with their infants. Klein and Stern (1981) found in examining 51 cases of child abuse, for example, that 24 per cent of the abused infants had been of low birth weight and had had an average hospital stay of 41 days, preventing normal early parenting.
It could be, however, that such early bonding would account for small but significant differences in mother-infant behaviour for most infants. As an example of such small differences, Pollitt and Lewis (1980a, 1980b) reported data from two studies showing that children who had been breast-fed tested on average one IQ point higher than those who had been bottle-fed. Effects of this size produced by neo-natal bonding would be difficult to detect.
The second period of bonding, commonly referred to as attachment, is primarily I-M and occurs, as noted earlier, between two and seven months. The breaking of this bond by changing the child's primary caretaker(s) between the ages of about 6 and 36 months tends to throw the child into a state of depression similar to that of hospitalized children (Bowlby, 1965). Malnutrition frequently follows. The reasons for this depression are not entirely a mystery. The caretaker is the child's source of stability. At the same time, the child, who is just learning to express itself in words and gestures, may build up an intimate personal communication system that only the primary caretakers understand and share. Given to an unfamiliar caretaker, this child is like an adult lost in a strange country without an interpreter. Basic trust is broken and the child is afraid to trust again for fear of another abandonment. The child tends to show rejecting behaviour towards the new caretaker(s) and long-term developmental probe lems frequently develop. The mending of such broken bonds may require extreme measures such as permitting the infant to physically cling to its new caretaker(s) and/or sleep in bed with the caretakers for weeks or months. Special strategies for repairing these bonds in older adopted children are under investigation.
Among infants with many shifting caretakers in day-care centres or extended families, the child may become more attached to the stability of the environment or the daily routine than to a single individual. Such infants may respond to a radical change in routine or environment with as much distress as others display to the loss of an individual caretaker.
Dixon and co-workers (1982) found that among the Gusii in Kenya, the majority of severely malnourished children in their study community had lost their mothers as primary caretakers and had also experienced neo-natal problems interfering with the early bonding experience. They suggest that the child's state at birth led to neo-natal bonding failure, as the malnourished, small-for-gestational-age (SGA) neonate was less able to interact with his caretaker. This early failure predisposed the vulnerable mother to leave the child in another's care or otherwise neglect him, resulting in a poorly bonded, depressed, and malnourished child.
Typologies of Faulty Interaction
Woolston (1983) describes three types of mother-child interactions that lead to male nutrition or non-organic failure-to-thrive in the United States. The extent to which this typology applies to other cultural contexts should be investigated. These are presented in table 4. Type 1, reactive attachment disorder of infancy, may correspond most closely to the concept of "benign neglect" defined by Cassidy ( 1980), a situation where the mother believes that she is being benevolent but is in fact neglectful. "The mother both undernourishes and under stimulates her infant. One would expect the mother to be emotionally unavailable, the infant to show developmental delays and an abnormal response to proximal interactions with others, and mother-infant interaction to be characterized by a paucity of warmth and nurturance."
We propose that a variant of this type occurs in developing countries where the mother is underinvesting in a child, while lacking the resources (time, food, future income, social support) to bring him up properly. The mother, herself, may not be psychologically abnormal but may feel personally conflicted and depressed over her relationship with the child, to whom she may behave warmly when not too emotionally stressed.
Anecdotal reports suggest such ambivalence in Pakistan. It is considered normal in Pakistani villages for a new mother to cry after giving birth to a daughter. These tears are believed to express both sorrow for herself that she has not delivered a son, and grief for the fate of the little one, who must endure the unhappiness of a woman's lot in life (Dr. Satnam Mahmood, personal communication. 1973).
Table 4. Three syndromes leading to malnutrition in infancy
|NFTT type I (reactive attachment disorder of infancy) Infants
|1. Significant developmental delays in motor, language and adaptive areas.
|2. Lack of developmentally appropriate signs of social responsivity as defined by DSM-I II in reactive attachment disorder of infancy.
|3. Onset of failure-to-thrive (FTT) before X months of age.
|1. Perceive their infants as sick.
|2. Psychopathology characterized by depression and social isolation.
|1. Few interactions indicative of pleasure and mutual social responsivity.
|2. Infants prefer distal to proximal interaction.
|3. Infants show apathy and/or active withdrawal in proximal and feeding interactions.
|NFTT type 2 (simple calorie-protein malnutrition)
|1. No or minimal developmental delays.
|2. Developmentally appropriate signs of social responsivity.
|3. Onset of FTT before 12 months.
|1. Perceive their infants as sick.
|2. No characteristic psychopathology or psychosocial disruptions.
|1. Frequent interactions indicative of pleasure and mutual social responsivty.
|2. Infants prefer proximal to distal interactions.
|3. Infants co-operative and vigorous in proximal and feeding interactions.
|NFTT type3 (pathological food refusal)
|1. No or minimal developmental delays.
|2. Developmentally appropriate signs of social responsivity.
|3. Onset of FTT between 6 months and 16 months.
|1. Do not perceive their infants as sick.
|2. Psychopathology characterized by depression and hostility.
|1. Few interactions indicative of mutual social responsivity and pleasure.
|2. Infants prefer distal to proximal interactions.
|3. Infants show angry withdrawal and active avoidance in proximal and feeding interactions.
Source: Woolston, 1983.
Type 2 represents simple calorie-protein malnutrition. The mother provides adequate stimulation for her infant but, as a result of misinformation or lack of re sources, does not provide adequate nutrition. One would expect the mothers to appear within normal limits on psychological testing, the babies to show no abnormalities except in growth, and the mother-infant interaction to be within normal limits.
This would appear to be the model most commonly addressed by nutritionists in developing countries, where a large proportion of infants are malnourished when measured by international standards. Inadequate cultural beliefs and practices account for misinformation, and poverty for lack of resources. As infants become more severely malnourished their capacity for normal interaction is, at least temporarily, reduced.
In type 3, pathological food refusal. "the infant is struggling to create autonomy from the mother. One would expect the mothers to be angry or depressed, the babies to show specific behavioural disturbances focused on food refusal but without developmental abnormalities, and the mother-infant interchange to be characterized by negative and angry interchanges."
Yet another type that may be common in developing countries, but is not often seen in industrialized countries and is not described by Woolston, has been termed breast addiction. Towards the end of the first or during the second year of life, the child refuses solid foods and insists on breast-feeding on demand. One American mother of a 16-month-old going through this phase nicknamed her daughter "Draculina" (connoting humorously that she felt attacked by a vampire trying to feed on her blood). From personal discussions with mothers in the United States, Nigeria, and Indonesia, whose infants displayed this pattern, the writer suggests that mother and infant are again locked in a power struggle in which the infant is trying to protect its exclusive rights to access to the comfort of the mother's body and to her attention against perceived competition from siblings or adults or from the mother's desire to terminate breastfeeding.
Discussion of Mother/Caretaker-Child Interactions
Figure 8 is a model showing that close and affectionate interactions between the mother and child (box 1) may promote growth both through greater maternal responsiveness to the child's needs (box 2) and by a direct physiological effect on the child (box 3). We have already introduced potential mechanisms for such physiological effects. This diagram also indicates that certain practices, behaviours, and technologies and their corresponding belief structures (box 6) may be more adaptive to resource scarcity than others, independently of the quality of the mother's psychological interactions with her infant.
Findings that Can Be Applied to Educational Messages
Messages conveyed to mothers encouraging them to hold, hug, play with, talk to, and kiss their babies frequently are important. Such advice may seem to some policy makers to be too obvious or simplistic or to insult the natural mothering abilities of their constituents. Yet many cultures have rules against "spoiling" infants which justify not responding to their cries and leaving them isolated for long periods. Some mothers apply these rules harshly, believing that it is for the good of the child. The rules are part of the obsolete ideology (referred to as adaptation type 3) that the infant must be taught to accept its subordinate rank in the family. The message "holding your baby will not spoil him" may be necessary.
Even where the culture reinforces attentive mothering, women who have recently migrated from extended family homes or whose personal support networks are weak or unstable for other reasons may need additional external encouragement to be attentive.
Little research has been done on behaviours that are specifically adaptive to resource scarcity. The study in Mexico reported by Zeitlin and Johnson (in progress) indicated that the mother's active, persistent feeding of toddlers appeared to overcome constraints of low nutrient density of the food and anorexia associated with high rates of infection. Many mothers believed that 12-month-old infants should be able to feed themselves independently. Messages conveying the idea that children at this age cannot eat enough by themselves, and that mothers should actively feed them, appeared appropriate.
Although useful educational messages are expected to develop from the results of further research into mother-child interactions, not all beneficial mother-child interactions can be transferred through education alone. When a mother engages in less than optimal forms of emotional interaction with her child because she herself is under stress or emotionally unprepared to satisfy the child's needs, a social-marketing approach that attacks individual behavioural elements may or may not be productive. Preaching to a depressed mother to "smile and be cheerful with your baby" could make the situation worse. On the other hand, the attempt to act cheerful with one's children even when feeling depressed is a part of good parenting. Social support that reduces the stresses in the mother's life in addition to providing her with minimal child-care counselling may be sufficient to revert the pathological interactions to normal ones.
Findings that Can Be Applied to Programme Design
Mothers who interact poorly with their infants need help. Current methods of treating interactions that are overtly pathological are very expensive. A recent estimate of the per family per year cost of intensive interventions to protect the physical and psychological development of infants in high-risk families in the United States was $850 (Greenspan, 1982).
Table 5 (Rathbun, 1979) shows all of the members of the failure-to-thrive team in a Boston area hospital. Each child exhibiting growth failure is assessed by the entire team and a multifactorial intervention is planned. The expense of assembling such professional teams to serve all high-risk children would obviously be prohibitive in most developing countries. Yet Alvarez in her recommendations to the 1985 International Union of Nutrition Sciences Workshop on Positive Deviance (Zeitlin and Ghassemi, 1986) suggested that pairing in a "buddy" system of competent low-income mothers or grandmothers (positive deviants) with high-risk mothers could be used to reduce pathological parenting. In the United States, in the New England towns of Braintree, Lawrence, Lowell, Waltham, and Taunton-Fall River, the Massachusetts Society for the Prevention of Cruelty to Children (MSPCC) runs such a pairing system in a project entitled the Good Start Program. The Ford Foundation also supports such a programme pairing teenage parents with mature parents in New York City and in Boston under the name Alliance for Young Families. If community-based, these pro"rammes can be inexpensive and have the potential to reduce interactional disorders, family stress and loss, poor infant feeding, and developmental delays.
Table 5. Multidisciplinary management of FFT
|Area of assessment and treatment
|1. Inadequate nutrition
|2. Attendant medical problems
|Stabilization of medical problems
|3. Developmental delay
|Developmental specialist (e.g. paediatrician, psychologist, physical therapist)
|Infant stimulation programme, physical therapy and social work services
|4. Family stress and loss
|5. Interactional disorder
|Infant behavioural status, maternal level of functioning, quality of parent-infant interaction
|Child psychiatrist, psychiatric nursel social worker
|Mental health services
|6. Long-term growth sequellae
|Nutrition counselling, close pediatric follow-up, frequent weighings
|Nutritionist, paediatrician, nurse
|Outpatient paediatric practitioner, visiting nurse, community nutrition service
Source: Rathbun, 1979.
Early childhood interventions that teach mothers to stimulate their infants' psychological development should also have a beneficial effect on growth status. A nutrition/health component in these programmes should enhance this effect.
Findings in this section also support existing recommendations that:
Although many writers mention in passing the fact that a child's innate activity level, initiative, aggressiveness, ability to communicative, and appetite will affect his nutrition-related interactions with his mother, few studies have looked at the ways in which child characteristics affect nutritional status.
Innate Differences between Children
Innate differences between children may affect nutritional outcome through a variety of mechanisms. Developmental psychologists continue to explore the contribution that innate characteristics make towards invulnerability, or the ability of the child to develop normally despite the presence of biological and social factors that increase the risk of behavioural disorders (Anthony and Cohler, 1987). The invulnerable child is a positive deviant with respect to psychological rather than nutritional outcomes. As we noted earlier, many factors that contribute to positive deviance in nutrition appear to be non-specific, in the sense that they also contribute to positive behavioural, cognitive, social, health, and other developmental outcomes. It is therefore reasonable to suspect that there are innate psychological capacities that predispose the child to establish an interaction pattern with its environment that is globally positive and therefore fosters good feeding interactions. Popular wisdom agrees that some babies are easy, good-natured, affectionate, friendly, and clever in getting what they want.
Psychological studies of invulnerability or resilience have focused on older children. The traits that they identify as contributing to the child's coping capacity may exist, however, in embryonic form in the infant. One such list is from Garmezy and associates (1975):
Behaviours specifically related to obtaining food also differ innately. One of the few studies relating feeding behaviour to food intake, by Pollitt and associates (1977), demonstrated that the infant's sucking behaviour regulates close to 40 per cent of the variance in his fluid intake (from the bottle) in the first month of life. The more vigorous and the more persistent the sucking, the more the infant drinks. The sucking strength of the newborn also influences the rise in serum prolactin in the mother which in turn is part of the feedback mechanism regulating breast-milk production. Research by Khin-Maung-Naing and co-workers (19X0) in Burma. in which malnourished mothers were studied in a clinical research centre, showed that more milk always remained in the breasts after the infant voluntarily stopped nursing. This milk, exe pressed manually immediately after each feed. was of significant volume even in the case of older malnourished infants.
Out of 20 well-nourished children between 8.5 and 20.5 months in a Mexican squatter settlement, Johnson and Zeitlin (in progress) found one little girl whose persistent demands for food and voracious appetite kept her growing normally despite very poor caretaking.
Associations between Good or Improved Nutritional Status and Child Behaviour
There are a large number of studies that have a bearing on the contribution of child characteristics to positive deviance although the innate characteristics of the child are not their focus. These are research efforts relating:
One of these studies (Chavez and Martinez, 1982) links the changed behaviours back to the child's performance in obtaining food.
This section will briefly review these effects. Figure 9, taken from Lester (1979), shows the hypothesized effects of pre-natal malnutrition on the infant's behaviour and its subsequent nutritional status. The malnourished infant has poor eliciting behaviours. Specifically, underweight newborns in Lester's study showed poorer perform mance than controls on the four Brazelton scale dimension scores of social integration, motor processes, organization of state, and physiological organization. Undernourished newborns have also been found to have low activity levels (Chavez and Martinez, 1982) and low tolerance for mild stress (More et al., 1977; Vuori et al., 1980). Lester (1979), Zeskind (as cited by Greenberg, 1983), and others have found underweight infants to have abnormal cries. These cries tend to sound more distressing to the mother than normal cries and may be less effective in eliciting her car responses. Zeskind suggests that the balance between the sympathetic and parasympathetic nervous systems is disordered in the "subtly malnourished" infants, who also display abnormal cardiac and respiratory rhythms. The quality of the infant's cry at 40 weeks gestational age has been found to predict its mental development at 18 months and at five years (Lester, 1987).
Fig. 9. Synergistic model of the effects of pre-natal malnutrition (after Lester, 1979).
Since many of these studies were done on relatively well-nourished populations, simple protein-calorie undernutrition may not be responsible for all of these disorders. Landers (1983), who conducted a longitudinal study of an undernourished group of infants in South India, does not report the deviations from normal development that might be expected if all lowweight infants displayed the above afflictions.
Nevertheless, the evidence overwhelmingly supports the conclusion that the positive-deviant infant is more likely to be of normal than of low birth weight. The neo-natal mortality rates of normal-weight newborns are many times lower than those of low birth-weight infants; their behavioural responses, better on average; and their long-term growth performance is also significantly better.
Supplementation of lactating mothers and of infants and pre-schoolers has been associated with:
The authors suggested that these demands occurred because the supplemented infant had experienced supplementary feeding and therefore knew enough to demand to share what the parents were eating. The supplemented infant also did not undergo the progressive loss of appetite experienced by infants kept only on the breast.
Discussion of the Role of Child Characteristics in Positive Deviance
The overall implications of these studies is that better nutritional status during pregnancy and infancy, achieved either naturally by the positive deviants in the population or by interventions such as supplementation or nutrition education, produces the potential for an upwards spiral - a more vigorous, demanding, perceptually capable child who is more efficient in obtaining food.
Researchers tend to agree that most effects of improved nutrition on young-child behaviour are short-term responses to improvement, contemporaneous with supplementation (Waber et al., 1981). At least one study does report, however, long-term benefits of short-term intervention, where supplementation during the first two years was associated with significant IQ differences at 8.9 years. Improved nutrition affects performance more than cognitive structures, by improving the child's ability to elicit and sustain attention (More et al., 1977). The belief that malnutrition causes irreversible loss in brain function because it diminishes the number of brain cells has not received strong scientific support. Although irreversible developmental lesions have been found in association with early malnutrition' nothing is known about their functional significance. Malnutrition in children living in developing countries is, however, consistently related to other environmental factors that may also interfere with the development of the brain.
Another principle of child development, important for understanding the longer term effects of pre-natal and young-child malnutrition, is that the effects of multiple sources of deprivation on development are more than additive. A child may develop entirely normally despite one form of deprivation (organic malnutrition in the absence of poverty, poverty in the absence of malnutrition, loss of father if mother is functioning well, etc. ) Nevertheless, if two or three types of deprivation or disability are added together simultaneously, the developmental process is likely to go off track. Infants who are not in optimal biological condition have been found to be at higher risk than biologically optimal infants of failing to develop normally in poor-quality post-natal environments (Breitmayer and Ramey, 1986). Nutritional state at any given point in time may play the role of the straw that breaks the camel's back with respect to longer term development.
The likelihood that nutrition will play this critical role probably is highest during pregnancy for the reason that pre-natal nutrition affects so many systems simultaneously, including:
The interrelationships between sucking strength and breast-milk supply illustrates the multiplicative nature of these relationships. Either adequate sucking or an abundant first milk supply is necessary to initiate functional breast-feeding. When both are simultaneously compromised lactation failure may occur.
If malnutrition compromises all of these systems at once, the child's chances for a favourable outcome may be reduced. Therefore, the likelihood of producing long term improvement through short-term intervention is probably highest during pregnancy. Of course, where pregnant women already are reasonably well-nourished, as in much of North Africa and the Middle East, such intervention would be much less effective.
Evidence that positive-deviant status depends on the nutritional state of the mother comes from the Emesi village study in Nigeria (Morley et al., 1968). At three months postpartum, mothers of the group who were subsequently above the 50th percentile of the local standard were on average 4.6 kilograms heavier than those whose infants later fell below the 10th percentile. Twenty-six per cent of the later malnourished group (50 infants total) and less than ] per cent of the later well-nourished fell below the 10th percentile for birth weight.
The preceding description of effects of nutritional status or nutritional supplementation on child characteristics applies to the intensity of reactions in children presumed to be psychologically healthy. As noted earlier, when the developmental process does go off track psychologically, in asynchronous dyads, the characteristics displayed by the child take on a qualitatively different, pathological character. Newberger et al. (1976) have described how the child's food refusal and withdrawal contribute to its own malnutrition in these circumstances.
In evaluating the child's contribution, the helplessness of the human newborn automatically implies that the mother's characteristics are more sigificant than those of the child in determining the quality of their interaction, and that she has a far greater repertoire of verbal and non-verbal gestures which are likely to stimulate responses in the infant.
Findings Applicable to Programme Design
Nutrition programmes appear to have strong potential for strengthening the infant's behavioural contribution to dyadic interaction and thereby increasing the chances of positive-deviant outcome.
Pre-natal nutrition affects the infant and mother simultaneously and may have a preprogramming effect on the child's growth and development through the pre-school years and later. Consequently, pre-natal nutrition programmes have a higher probability than short-term post-natal interventions of producing long-term effects on infant characteristics. Effects of postnatal weaning-food programmes on infant behaviour are likely to last only so long as the child's improved status is maintained during the period of programme intervention. A programme that continues, however, to reach the child until the end of the second or third year protects him across the most vulnerable period. Food-eliciting behaviours, even of malnourished children, tend to improve spontaneously by this age.
In the future, when the child's own contribution to nutritional outcome is better understood, it may be practical to screen for infants who are at high risk of becoming malnourished because of their own behavioural characteristics. While some characteristics of high-risk newborns are known, they have not yet been systematically linked to subsequent growth and development.
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