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

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

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

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

Determinants of aggressive and prosocial behaviour among Jamaican schoolboys.

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

Assessments of the effects of nutrition on mental development and behavior in Jamaican studies.

Methodological issues and problems in studies of the effects of protein-energy malnutrition (PEM) and child development are discussed with reference to our experience in Jamaica. The usefulness of defining PEM by stunting, wasting, and edema is stressed. Difficulties in achieving reliable and valid measurements of mental development and behavior in Third World children, and allowing for the confounding and possibly interacting effects of social background, are discussed. Problems associated with different approaches are outlined.

Effects of missing breakfast on the cognitive functions of school children of differing nutritional status.

We examined the effects of omitting breakfast on the cognitive functions of three groups of children: stunted, nonstunted controls, and previously severely malnourished. They were admitted to a metabolic ward twice. After an overnight fast half the children received breakfast on their first visit and a cup of tea the second time. The treatment order was reversed for the other half. When breakfast was omitted, both the stunted and previously malnourished groups responded similarly. The malnourished groups had lower scores in fluency and coding whereas the control group had higher scores in arithmetic. The children were divided into wasted and nonwasted groups. Wasted children were adversely affected in the digit span backwards tests, and wasted members of the malnourished groups were adversely affected in efficiency of problem solving and those in the control group in digit span forwards. These results indicate that cognitive functions are more vulnerable to missing breakfast in poorly nourished children.

The ecology of nutritional status and development in young children in Kingston, Jamaica.

A survey of two poor neighborhoods in Kingston, Jamaica is reported. The nutritional status in children under 48 months (309) and the developmental levels of children between six and thirty months (168) were assessed. Characteristics of children with poor nutritional status and development were identified. Thirty-one percent of the children had Gomez grade 1 malnutrition, 9% had Gomez grade 2, and 1.6% had Gomez grade 3. There was somewhat more stunting than wasting. Nutritional indicators, weight for age and weight for height, as well as developmental levels declined with the children's age. Children with poor nutritional status tended to be girls, have poor housing, mothers with low levels of education, and mothers who worked. Children with low developmental quotients (DQs) tended to be boys and have mothers who worked. Multiple regression analysis showed that stunting (ht/age) and weight for age had significant effects on DQ, whereas wasting (wt/ht) did not.

Stress response in school-age children who have been growth retarded since early childhood.

BACKGROUND: Approximately 39% of children aged <5 y in developing countries are growth retarded (stunted) and many have poor mental development and behavioral abnormalities. Animal research suggests that an altered stress response may contribute to the negative outcomes following undernutrition. OBJECTIVE: We tested the hypothesis that stunted children have higher salivary cortisol concentrations and heart rates and altered behavior when compared with nonstunted children when social background was controlled for. DESIGN: We compared 30 stunted with 24 nonstunted children, all of whom were 8-10 y old and lived in the same poor areas of Kingston, Jamaica. All subjects were participants in a prospective, longitudinal, case-control study of children who were stunted in early childhood. We administered a test session (including psychologic and physical stressors), measured baseline and response levels of salivary cortisol and heart rate, and observed behavior. RESULTS: Compared with nonstunted children, stunted children had higher salivary cortisol concentrations (P = 0.007), had higher heart rates during the psychologic test session (P = 0.03), exhibited enhanced cardiovascular responsivity to a physical stressor (P = 0.04), vocalized less, were more inhibited, and were less attentive. After birth weight or social background and maternal and child intelligence quotients were controlled for, the differences in cortisol concentration and cardiovascular reactivity remained significant. CONCLUSIONS: Our findings suggest that consistent growth retardation since early childhood affects physiologic arousal, which, we speculate, may contribute to the poor cognitive functioning and immune responses of stunted children and the relation between adult short stature and increased cardiovascular risk.

Key issues in generating a psychological-testing protocol.

An individual's behavior is created by an amalgam of genetic, environmental, cultural, and historical variables working in concert and changing over time. Variations in nutrition are one class of environmental factors. Linking these to outcome effects requires carefully designed studies. Many considerations are involved, and this paper draws attention to some of the fundamental ones. Psychological and behavioral functions tend to be complex, in part because they are affected by a wide range of variables. Almost any given state--a particular constellation of psychological characteristics displayed by an individual at a given time--can be produced in a variety of ways.

Evaluation of school feeding programs: some Jamaican examples.

It is hypothesized that giving children a daily breakfast at school may improve their scholastic achievement through several mechanisms: increasing the time spent in school, improving certain cognitive functions and attention to tasks, and, perhaps indirectly, improving nutritional status. Two Jamaican studies showed that providing breakfast to students at school improved some cognitive functions, particularly in undernourished children. However, changes in classroom behavior varied depending on the quality of the school. Children in better-organized schools concentrated on tasks for longer periods and made fewer undesirable movements, whereas in poorly organized schools the children's behavior deteriorated. Studies to date have provided insufficient evidence to determine whether children's long-term scholastic achievement is improved by eating breakfast daily. Well-designed, randomized, controlled, long-term trials are essential for determining public policy on the implementation of school feeding programs.

Morbidity and the growth of stunted and nonstunted children, and the effect of supplementation.

Children aged 9-24 mo were recruited by a survey of poor areas of Kingston, Jamaica. Stunted children were randomly assigned to supplementation or not. Weekly morbidity histories were taken for 2 y. Separate multiple regressions on each symptom for weight or length gain in 2-mo intervals showed significant reductions in weight gain with coughing, apathy, anorexia, diarrhea, and fever, ranging from -2.1 to -16.8 g/d ill. Apathy and diarrhea reduced gains in length (-0.26 and -0.20 mm/d ill). Significant reductions in linear growth with lower respiratory-tract infections (-0.16 mm/d ill) occurred only in nonsupplemented children. Growth over 4-mo intervals was reduced if diarrhea occurred in the first 2 mo of the interval but there were no long-term effects of apathy, fever, or anorexia. Some of the effects of morbidity on growth were therefore transient and morbidity is unlikely to be a major cause of growth retardation in this population.

Nutritional supplementation, psychosocial stimulation, and growth of stunted children: the Jamaican study.

The benefits of nutritional supplementation, with or without psychosocial stimulation, on the growth of stunted children were evaluated. Children aged 9-24 mo with lengths less than -2 SD of the National Center for Health Statistics references (n = 129) were randomly assigned to four groups: control, nutritional supplementation, stimulation, and both interventions. A fifth group with lengths greater than -1 SD was also enrolled. Length, weight, head and arm circumferences, and triceps and subscapular skinfold thicknesses were measured on enrollment and 6 and 12 mo later. Multiple-regression analysis was used to determine the effects of the interventions in which age, sex, initial status, initial dietary intake, and several socioeconomic variables were controlled for. Stimulation had no effect on growth and there was no interaction between the interventions. After 12 mo supplemented children had significantly increased length, weight, and head circumference (all P less than 0.01). The effects of supplementation were not cumulative but occurred in the first 6 mo.

Effects of early childhood supplementation with and without stimulation on later development in stunted Jamaican children.

It is not known whether nutritional supplementation in early childhood has long-term benefits on stunted children's mental development. We followed up 127 7-8-y old children who had been stunted in early childhood and received supplementation, stimulation, or both. At 9-24 mo of age, the children had been randomly assigned to four treatment groups: nutritional supplementation, stimulation, both treatments, and control. After 2 y, supplementation and stimulation had independent benefits on the children's development and the effects were additive. The group receiving both treatments caught up to a matched group of 32 nonstunted children. Four years after the end of the 2-y intervention 97% of the children were given a battery of cognitive function, school achievement, and fine motor tests. An additional 52 nonstunted children were included. Factor analyses of the test scores produced three factors: general cognitive, perceptual-motor, and memory. One, the perceptual-motor factor, showed a significant benefit from stimulation, and supplementation benefited only those children whose mothers had higher verbal intelligence quotients. However, each intervention group had higher scores than the control subjects on more tests than would be expected by chance (supplemented and both groups on 14 of 15 tests, P = 0.002; stimulated group in 13 of 15 tests, P = 0.01), suggesting a very small global benefit. There was no longer an additive effect of combined treatments at the end of the intervention. The stunted control group had significantly lower scores than the nonstunted children on most tests. Stunted children's heights and head circumferences on enrollment significantly predicted intelligence quotient at follow-up.

A method to estimate prevalence of iron deficiency and iron deficiency anemia in adolescent Jamaican girls.

A method is presented to estimate a cutoff for hemoglobin concentration appropriate for estimating the prevalence of iron deficiency anemia in poor Jamaican girls 13-14 y of age. Iron deficiency was determined from a three-variable model of iron status (serum ferritin, erythrocyte protoporphyrin, and mean corpuscular volume). The most appropriate hemoglobin cutoff was considered the one that minimized misclassification of iron deficiency: that yielding the maximum kappa coefficient for correctly classifying iron deficiency between 100 and 120 g/L, at 1-g/L intervals. By using this method, a hemoglobin cutoff of 107 g/L was considered most appropriate. This cutoff and the other indicators were used to estimate prevalence of iron deficiency and iron deficiency anemia in the Jamaican girls: 7.6% and 4.3%, respectively. This approach should be appropriate for determining hemoglobin cutoffs for iron deficiency anemia in other populations.

Nutrition and education: a randomized trial of the effects of breakfast in rural primary school children.

Hunger during school may prevent children in developing countries from benefiting from education. Although many countries have implemented school feeding programs, few programs have been rigorously evaluated. We conducted a randomized, controlled trial of giving breakfast to undernourished and adequately nourished children. The undernourished group comprised 407 children in grades 2-5 in 16 rural Jamaican schools (weights-for-age < or = -1 SD of the National Center for Health Statistics references) and the adequately nourished group comprised 407 children matched for school and class (weights-for-age >-1 SD). Both groups were stratified by class and school, then randomly assigned to breakfast or control groups. After the initial measurements, breakfast was provided every school day for 1 school year. Children in the control group were given one-quarter of an orange and the same amount of attention as children in the breakfast group. All children had their heights and weights measured and were given the Wide Range Achievement Test before and after the intervention. School attendance was taken from the schools' registers. Compared with the control group, height, weight, and attendance improved significantly in the breakfast group. Both groups made poor progress in Wide Range Achievement Test scores. Younger children in the breakfast group improved in arithmetic. There was no effect of nutritional group on the response to breakfast. In conclusion, the provision of a school breakfast produced small benefits in children's nutritional status, school attendance, and achievement. Greater improvements may occur in more undernourished populations; however, the massive problem of poor achievement levels requires integrated programs including health and educational inputs as well as school meals.

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

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

Home visiting of varying frequency and child development.

Two studies were made of home visiting and psychosocial stimulation with deprived urban children in Jamaica. The aim was to determine the relative effectiveness of different frequencies of visiting on the children's developmental levels and the feasibility of integrating the model into government primary health care services. Health paraprofessionals supervised by a nurse from a local health center conducted the intervention. In the first study, 152 children aged 6 to 30 months were assigned to groups visited biweekly, monthly, or not at all by area of residence. The biweekly group showed small but significant increases in scores on the Griffiths Mental Development Scales (developmental quotient) and performance subscale compared with the monthly and control groups, whereas no benefit was shown in the Griffiths scores of the monthly group. In the second study, 58 children aged 16 to 30 months from the same neighborhoods were randomly assigned to weekly visited and control groups. The group visited weekly showed marked improvements in the performance and hearing and speech subscales as well as the developmental quotient scores. The results indicate that as the frequency of visiting increases from none through monthly and biweekly to weekly, the benefits increase as well.

Development of severely malnourished children who received psychosocial stimulation: six-year follow-up.

The development of 16 children who were hospitalized for severe malnutrition and participated in a home-visiting program of psychosocial stimulation was compared with that of two other groups who were also hospitalized but received standard medical care only: severely malnourished group (n = 18) and an adequately nourished one (n = 20). All groups were assessed regularly on the Griffiths Mental Development Scales and the Stanford-Binet test. Both groups of malnourished children were markedly behind the adequately nourished group on admission to the hospital and the group that received no intervention showed little sign of catching up. The intervention group caught up to the adequately nourished group in 2 years. This report covers the third year of home-visiting and the 3 years following its cessation. The intervention group showed a decline in three of the five Griffiths subscales. However, they retained a marked advantage over the nonintervention group of malnourished children on the Stanford-Binet test until the end of follow-up, showing no further decline in the last year. For height, both malnourished groups failed to catch up to the adequately nourished group. It was concluded that a relatively simple intervention can benefit the development of severely malnourished children.

Effect of psychosocial stimulation on mental development of severely malnourished children: an interim report.

The effect of adding psychosocial stimulation to the treatment of severely malnourished children was studied. The study period covered children from the time they left the hospital to 24 months later. The children's developmental levels (DQs) were compared with those of two other groups who were in the hospital--an adequately nourished group with diseases other than malnutrition, and a severely malnourished group who received standard hospital care only. The children receiving intervention had structured play sessions in the hospital and were visited weekly for 2 years after returning home. During the visits paraprofessionals showed mothers how to continue structured play with their children. The malnourished children who did not receive intervention showed a marked deficit in developmental level compared with that of control children throughout the study. The control children showed a decline in developmental level with age, which is characteristic of disadvantaged children. The children receiving intervention showed marked improvements and by 24 months were ahead of the children who did not receive intervention in every subscale and were head of the adequately nourished children in two subscales. Both groups of malnourished children remained behind the control children in nutritional status and locomotor development.

Parasitic helminth infection and cognitive function in school children.

The study examines the effect of moderate to high worm burdens of Trichuris trichiura infection on the cognitive functions of 159 school children (age 9-12 years) in Jamaica, using a double-blind placebo-controlled protocol. Results were evaluated by using a forward-stepwise multiple linear regression. Removal of worms led to a significant improvement in tests of auditory short-term memory (p less than 0.017; p less than 0.013), and scanning and retrieval of long-term memory (p less than 0.001). Nine weeks after treatment, there were no longer significant differences between the treated children and an uninfected Control group in these three tests of cognitive function. It is concluded that whipworm infection has an adverse effect on certain cognitive functions which is reversible by therapy.

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

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