When science and politics listen to each other: good prospects from a new school breakfast program in Peru.

This article provides an overview of a school breakfast program implemented in 1993 in the Peruvian Andes. The program, designed by the Instituto de Investigación Nutricional in Lima and supported by the government of Peru, constitutes a clear departure from previous school feeding programs, which were heavily politicized and poorly documented. From the program's inception, nutritionists, managers, and social scientists have collaborated to produce a sound nutritional design, efficient distribution mechanisms, and effective evaluation methods. During the program's first year, controlled evaluations conducted in several Andean regions documented improved dietary intake and a significant decline in the prevalence of anemia. An educational evaluation also found improved verbal skills, higher school attendance, and lower dropout rates among recipients of the school breakfast. The results have prompted the Peruvian government to continue supporting the program, thus setting a new standard for the effective management of social expenditure in the context of economic adjustment.

Effect of removing Ascaris on the growth of Guatemalan schoolchildren.

OBJECTIVE: To determine whether successful deworming for 6 months in children with high levels of Ascaris improves physical growth. SUBJECTS: Two hundred twenty-eight children (mean age, 9.7 years) in a highland Indian town in Guatemala. DESIGN: Children were randomly assigned to receive albendazole or placebo at baseline and 12 weeks. Children and field workers were both blind to the group assignment. OUTCOME MEASURES: Children's heights, weights, and mid-upper-arm circumferences were measured at baseline and 12 and 24 weeks. Fecal egg counts were taken at 0, 2, 12, 14, and 24 weeks to estimate the helminth burden (eggs per gram of feces [epg]). RESULTS: Baseline helminth prevalences were Ascaris, 91%, and Trichuris, 82%. Ascaris intensities were high: half of the children had moderate burdens (10 000 to 50 000 epg), and 25% had heavy burdens ( > 50 000 epg). Trichuris burdens were light (72% < 1000 epg). The albendazole and placebo groups did not differ at baseline in epg, age, anthropometry, or socioeconomic status. The two rounds of treatment successfully reduced the Ascaris burdens but had less effect on Trichuris. At 6 months the treatment group showed a small gain in weight (0.18 kg) compared with the placebo group but no improvement in height or mid-upper-arm circumference. CONCLUSIONS: The successful removal of ascaris in a population of school-aged children with relatively high loads may have modest effects on weight gain. Ascaris is one of the most common infections in school-aged children, but its effect on the host may be less than that of other helminths.

Does schooling buffer the effects of early risk?

The data presented here come from a 20-year study conducted in a rural area of Guatemala. Data on early biological indicators, graduated parameters of social structure, and preschool cognition were combined into a risk scale and analyzed in relation to primary school grade attainment and adolescent psychoeducational test performance. Similar to empirical relations reported in industrialized countries, performance declined as the number of risk factors to which a subject was exposed increased. More important, primary education was observed to buffer the effects of early risk for a subset of subjects. Subjects at high risk who stayed in school performed significantly better than subjects with similar levels of risk who completed fewer than 4 years of primary school.

School breakfast and cognition among nutritionally at-risk children in the Peruvian Andes.

PIP: In 1993, in Peru, the Institute of Nutritional Research conducted two studies in Huaraz in the Andean region to evaluate the educational and nutritional impact of the government's School Breakfast Program. The school breakfast included a small cake and a glass of Amilac (similar in taste and color to milk), which provided 30% of each child's energy requirements, 60% of recommended dietary allowances for minerals and vitamins, and 100% of dietary iron needs. A case control study examined the effects of breakfast on cognition among 54 elementary schoolchildren 9-11 years old. It found that the school breakfast did not have a significant effect on the children's performance in the Number Discrimination, Peabody Picture Vocabulary Test, Raven Progressive Matrices, or Reaction Time tests. Children nutritionally at risk who received the placebo had significantly slower short-term memory scanning than their counterparts who received the breakfast. The no-risk placebo group exhibited more rapid discrimination between visual stimuli than the no-risk breakfast group. A field evaluation of the program in 10 rural schools, which were randomly assigned to a treatment or control condition, was conducted. In terms of energy, protein, and iron intake, the children in the case and control conditions were not significantly different. The children tended to be either very stunted or overweight. School attendance increased 0.58 points in the experimental group, while it decreased by 2.92 points in the control group (p 0.05). When both groups received the breakfast, attendance rates increased significantly in both groups (p 0.05). Vocabulary was sensitive to the effects of the breakfast. Specifically, the greater the child's weight, the higher his/her vocabulary test scores (p 0.05). These findings suggest that the brain is sensitive to decreases in the short-term availability of nutrients, and that an overnight and morning fast produces a physiological state accompanied by changes in brain function, especially working memory, particularly among nutritionally at-risk children.^ieng

The effects of deworming on indicators of school performance in Guatemala.

Intestinal helminths are among the most common infections in school-age children. Of 246 children, aged 7-12 years, attending school in rural Guatemala, 91% carried Ascaris lumbricoides and 82% carried Trichuris trichiura. These children were randomly assigned to receive either albendazole or placebo at 0 and 12 weeks in a 'double-blind' study of the effects of deworming on indicators of school performance. Albendazole successfully rid the children of Ascaris but it was less effective against Trichuris. The children's performance in tests of reading and vocabulary were measured at 0 and 24 weeks, the Peabody picture vocabulary test was given at 24 weeks, and attendance was measured throughout the school year. Comparison of the treated and placebo groups showed no positive effect of deworming. The treated children were largely free of Ascaris for at least 6 months, but during that period we could not detect any improvement in reading, vocabulary, or attendance. The effects of being Trichuris-free were not examined because of the limited effectiveness of albendazole against this worm at the dosage used.

Malnutrition, poverty and intellectual development.

PIP: New findings with important policy implications have revealed that malnutrition in childhood impairs intellectual function in more ways than was previously recognized, but also that some of the damage to the brain caused by malnutrition may be reversed. Early research indicated that malnourished animals lacked the energy to interact with their environment and, thus, performed poorly on tests of mental ability. To determine the effect of poor diet and an impoverished environment on mental development in humans, an extensive follow-up study was made of Guatemalan children who received two different nutritional supplements in a 1969-77 study. Mothers and children in two villages received a high-protein supplement (Atole), and those in two additional villages received a supplement with no protein (Fresco). Both supplements reduced mortality, but Atole villages saw a 69% reduction in infant mortality (vs. 24% in the Fresco villages). The 1988-89 follow-up of 70% of the original participants involved extensive cognitive testing and socioeconomic assessment. Atole subjects performed significantly better on the cognitive tests, and the lowest-income children did as well as their more economically advantaged (but still poor) peers. Those who received Atole exhibited an increased benefit from their years of education and grew up faster and stronger than those who received Fresco. Smaller children who appear younger than their age may receive less stimulation from adult expectations than larger children. These findings indicate that the deleterious effects of early malnutrition on intellectual development can continue into adulthood. Other research has revealed that iron supplements can improve the intellectual and motor abilities of infants. While enriched educational programs can ameliorate some of the problems associated with malnutrition, poor children rarely live where such programs are available. The best and least expensive policy would be to prevent malnutrition among young children who would then be able to take advantage of the money invested in schools for their education.^ieng

Does breakfast make a difference in school?

This article reviews selectively the literature on the effects of breakfast on cognition and school performance. The focus is on studies published in refereed journals after 1978 that tested those effects on well-nourished and nutritionally at-risk children. In at-risk subjects (defined by clinical history and anthropometry), a morning and overnight fast had adverse effects on cognition, particularly the speed of information retrieval in working memory. Contradictions in the data from different studies prevent definitive conclusions on whether well-nourished children experience similar functional deficits. Nonetheless, available information suggests that brain function is sensitive to short-term variations in the availability of nutrient supplies. Moreover, well-conducted evaluations suggest that the availability of feeding programs in public schools throughout the academic year increases the probability that children will eat breakfast and improve their educational status.

Growth improvements in children above 3 years of age: the Cali Study.

The Cali Study involved the random assignment of 301 malnourished children to be exposed to one (CT1, n = 113), two (CT2, n = 64), three (CT3, n = 62) or four (CT4, n = 62) 9-mo periods of a multifocal day care-based intervention (i.e., education, health and nutrition). The ages at which the intervention was initiated for Groups CT4, CT3, CT2 and CT1 were 3.5, 4.2, 5.2 and 6.1 y, respectively. After the experimental phase, children were followed up in elementary school until they were 10.4 y old. Our secondary data analyses show that children who were exposed at an earlier age and for a longer period of time showed the highest degree (P < or = 0.05) of improvement in weight and linear growth during the pre-school period. These improvements in physical growth could no longer be detected 3 y after the termination of the intervention.

Determinants of lactation performance across time in an urban population from Mexico.

We identified determinants of breastfeeding and full breastfeeding among 165 healthy mothers from Hermosillo, Mexico who planned to breastfeed and delivered vaginally a healthy term infant. Deliveries took place in either a nursery (n = 58) or a rooming-in (n = 107) public hospital where formula supplementation was not allowed. Multivariate analyses indicated that at 1 week full breastfeeding was associated (P < or = 0.05) with early milk arrival, social support for full breastfeeding and planned breastfeeding duration. At 2 months, full breastfeeding was associated with social support for full breastfeeding and early milk arrival. Breastfeeding was positively associated with early milk arrival and inversely associated with early introduction of supplementary bottles, maternal employment, maternal body mass index and infant age. At 4 months, full breastfeeding was positively associated with social support for full breastfeeding and inversely associated with infant age. Breastfeeding was positively associated with planned breastfeeding duration and inversely associated with early introduction of a bottle and urban background. Rooming-in mothers reported that their milk came in earlier (P < or = 0.05) than did the nursery group. Milk arrival was later when a bottle was introduced in the first week; both of these variables might be important in explaining a positive effect of rooming-in on lactation performance.

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.

Effect of the maternity ward system on the lactation success of low-income urban Mexican women.

We compared the lactation performance of 165 healthy mothers who planned to breastfeed and gave birth by vaginal delivery, without complications to a healthy infant in either a nursery (NUR) (n = 58) or a rooming-in hospital where formula supplementation was not allowed. In the rooming-in hospital, women were randomly assigned to a group that received breastfeeding guidance during the hospital stay (RIBFG) (n = 53) or to a control group (RI) (n = 54). Women were interviewed in the hospital and at 8, 70 and 135 days post-partum (pp). The groups were similar in socio-economic, demographic, anthropometric, previous breastfeeding experience and prenatal care variables. Non-parametric survival analyses adjusting for potential confounding factors show that breastfeeding guidance had a positive impact (P < or = 0.05) on breastfeeding duration among primiparous women who delivered in the rooming-in hospital. Among primiparae, the RI and RIBFG groups had higher (P < or = 0.05) full breastfeeding rates than the NUR group in the short term. In the longer term, only the difference between the RIBFG and the NUR group remained statistically significant. The maternity ward system did not have a statistically significant effect on the lactation performance of multiparae.

Iron deficiency and behavioral development in infants and preschool children.

This paper selectively reviews the main findings of studies on the possible effects of iron deficiency on cognitive function among infants and preschool children published after 1976, and presents data from a study recently conducted in rural Guatemala. In comparison to infants without signs of sideropenia, infants with iron deficiency with and without anemia tend to score lower in the Bayley Scale of Mental Development; conversely, there is no evidence for an association between iron deficiency and delayed motor development. Iron repletion therapy implemented over a period of 7 to 10 days is likely to result in an improvement in mental development scale scores among infants with iron deficiency with or without anemia. In comparison with preschool children without sideropenia, preschool children with iron deficiency with or without anemia are less likely to pay attention to relevant cues in problem solving situations.

Evaluación de la conducta en los estudios sobre consecuenciasfuncionales de la malnutricion: descripcion de métodos

El presente trabajo se divide en dos partes. En la primera se presenta una descripcion breve de los métodos que se utilizan en estudios sobre el terreno para evaluar las consecuencias funcionales sobre la conducta de la malnutricion proteico-calorica y la deficiencia de hierro. La segunda parte consiste de una descripcion mas detallada de un paradigma teorico sobre la atención y el aprendizaje, y las pruebas derivadas de este, que fueron utilizados en estudios realizados en Estados Unidos de América y Guatemala. Tambien se presenta una bibliografía a fin de que el documento resulte de utilidad practica a los investigadores que preparan estudios en este campo

The relation of growth to cognition in a well-nourished preschool population.

This paper focuses on the nature of the physical growth-behavioral development association in well-nourished as compared with undernourished populations. Multiple regression analyses were calculated to determine the magnitude of IQ variance accounted for by physical growth variables and socioeconomic status indicators in a group of 3- to 6-year-old children from Cambridge, Massachusetts. The prevalence of malnutrition within this sample was negligible. Weight-for-height percentile was the only physical growth measure that explained a significant portion of the IQ variance. This finding contrasts with what is found in undernourished populations where height is generally the most potent explanatory variable of mental test score variance. In undernourished populations height is a reflection of nutritional history; in well-nourished populations weight-for-height is an indicator of physiological maturation.

Child poverty in South America: reflections on its magnitude, and the basic-need developmental approach. A retrospect on the International Year of the Child.

Extreme economic poverty in children with its adverse consequences on their mental and physical growth is becoming an increasing concern of governments in South America. There is now a search for effective intervention strategies to alleviate these problems as they are also a bottleneck for national development. Some of these programs are likely to be defined as fitting within the general theoretical framework of the basic-need approach to development. This paper postulates that intervention programs (e.g., nutrition, health and education) directed to economically deprived children will not be successful and are not representative of the basic-needs approach unless they also attend to the broader economic and social needs of families and communities. Although child-directed programs have proven to be moderately successful they do not eliminate the mental and physical growth differences between children determined by economic inequality.