Robert Karp, MD
SUNY-Downstate Medical Center
Pretest
Q1. True or false. Providing iron to an iron deficient infant is likely to improve development even when there is no psycho-social intervention.
Q2. Pick best answer An infant of an alcoholic mother, still drinking though pregnancy, who demonstrates none of the dysmorphologies of fetal alcohol syndrome is likely to show the behavioral and developmental problems associated with alcohol in-utero because
a. There are subtle effects that are not recognizable
b. Living with alcoholic parents is likely to affect development
c. Both "a" and "b"
d. Neither "a" nor "b"
Q3. True or false Malnutrition is associated with a downward trajectory in opportunities for success when experienced in the context of an impoverished environment.
Q4. True or false. Lead poisoning affects child development without respect to hematologic status.
Objectives
On completion of this section, residents and physicians will be able to:
1. Assess the impact of poverty on the risk for both malnutrition and developmental delay.
2. Describe effects of a) Inadequate nutrients (protein, energy, vitamin and mineral) and b) Excess ""anti-nutrients"" (lead and alcohol) on neuro-development.
3. Show how malnutrition at sensitive phases in development affects the way children experience the environments in which they live.
4. Recognize that malnutrition is a covariate that affects development in an interactive model rather than by direct cause and effect, and
5. Develop models for intervention that address nutrition in the context of an over-all approach to the psychological, social, and economic resources of the family.
Facilitator's Preparation
This module is based on updated material from two chapters in Malnourished Children in the United States: Caught in the Cycle of poverty (Springer Publishing Company of New York. 1993).
1. "Environment and the Development of disadvantaged children"" by Theodore Wachs, and
2. "The ecology of poverty, undernutrition, and learning failure"" by Trevor Sewell, Vivian Price, and Robert Karp.
3. Dr. Wachs'' publication, Necessary but not sufficient (2002) American Psychological Society. Washington DC is a compendium of information on the interactions of factors affecting child development.
4. Shonkoff JP, Phillips DA, eds. (2000) From neurons to neighborhoods: the science of early child development. Committee on Integrating the Science of Early Childhood Development. Washington, DC: National Academy Press, 2000.
Dr. Karp has published the chapters:
5. "The impact of poverty on the nutrition of children in the United States"" in Shils ME, et al (eds) Modern Nutrition in health and Disease. Editions 9 and 10 (1999 and 2005) Lippincott Williams Wilkins, Baltimore, MD. Material from these works has been incorporated into the module.
Useful contemporary reviews are:
6. Grantham-McGregor S, Am J Clin Nutrition 2001; 131: 649S-668S.
7. Galler JR, Barrett LR. Ambulatory Child health 2001; 7: 85-95.
An appendix is provided at the end defining concepts essential for an understanding of the relation between environment and experience.
Background
Abundant data show an association among poverty, undernutrition and impaired cognitive development in both industrial and non-industrial societies in all regions of the world where studies have been conducted. Both degrees of poverty and economic disparity are clearly reflected in the growth and nutritional status of children. We need no further studies showing that poverty creates an inherent risk for both malnutrition and developmental delay. Rather, it is necessary to study the effectiveness of intervention. Single-factor interventions are certain to fail. A variety of multi-factor interventions are both possible and necessary. Those most likely to succeed will address specific variables affecting the experience of children in their own environments.
Experience is not the same as environment. Environment refers to an objective situation -- the stimuli, responses or opportunities that a person encounters. By contrast, experience refers to those aspects of an environment that actually influence the development of the child. The same environment will not influence everyone in the same way. Variations in response are mediated by very specific characteristics of individual children.
One must ask, ""What was the earlier nutritional status as compared to the present? Was there exposure to lead in-utero or infancy or alcohol in utero?"" How these deficiencies or toxic substances affect subsequent development and behavior will depend on the following factors:
This last phenomenon is called "the experience of environment". An older child or adult who has lived through childhood malnutrition experiences life differently than one who has not? Characteristic that mediate children's response to the environment include nutritional status, gender, biologic vulnerability, temperament, activity level, and various personal qualities including self-regulation, energy level, and resilience. Simply stated, malnutrition at critical phases in development will affect the ways children experience the environments in which they live. An earlier accepted "cause and effect" [See Wachs, 1993 and 2002 for further comment] model by which poverty and malnutrition in one generation is replicated in next and succeeding ones--
Poverty --> Malnutrition --> Learning failure --> Continued poverty
is of limited value. Malnutrition is almost never an isolated event in the life of an affected child. A more complete model would be:
Figure 1.
In this model, poverty as well as a host of poverty associated phenomena would influence maternal education, willingness, and ability to purchase nutritious food. This is a covariate model. That is, the relations between nutrition and environment are not linear. The effect of one factor upon an outcome depends upon the level or characteristic of the others. While growth retardation, iron deficiency and lead poisoning directly affect on neuro-development, they increase risk for school failure and social dysfunction rather than determine outcome in life...
Thus, simply addressing undernutrition (iron deficiency and/or growth retardation) or lead poisoning alone without a multi-system approach to intervention is a certain prescription for failure. As Sally Granthum-McGregor writes,
"It is naive to expect mono-focal interventions, in the presence of extremely deprived environment, to produce substantial and long-term benefits to the children's development."" (see conclusion of PAHO monograph, 2000)
The "take-home" message is that a multi-system approach is essential to address the impact of malnutrition and learning failure in the context of chronic poverty.
Stop for discussion
Ask the participants to discuss their own experiences:
1. Compare siblings, other relatives, and friends who seem to come from the same environment but have very different outcomes in life.
2. Describe a sibling or other relative whose life experience has differed from that expected by parents or others from a similar background.
3. Emphasize that ""different"" is not necessarily bad in a socioeconomic environment that is supportive.
4. Ask what outcomes might be expected in different environments.
Case studies:
This module presents two case studies. The first case is that of a child with fetal alcohol syndrome. The pregnancy is wretched in terms of the nutritional environment of the fetus, but the child is adopted into the caring, competent, non-alcoholic family of a relative. [See module on FAS]
The second case is of a child of poverty though not of conscious neglect. An impoverished mother with little education has too many children. There is an overworked and under educated father. The child in question has iron deficiency and is growth retarded. His lead level is below the CDC limit of 10 ug/dL but above the level of 5 ug/dL that contemporary research is showing as toxic.
There is far too much material provided here for a single presentation. One could set up a short course, or alternatively, pick one case and use material from the entire packet to bring out specific points of importance to the learners.
Case #1 Janie S -- unrecognized fetal alcohol syndrome
This case addresses the impact of an insult occurring in-utero affecting the responsiveness of the child to a supportive environment later in life.
Janie S was the third born child to a single mother. Her mother lived in a small town in Indiana and worked at a local bar and restaurant as a waitress and some-times dance hall girl, at least before her pregnancies. The father of the first two children ran the local garage and was the principal caretaker. Their relationship was deteriorating when Mrs. S announced that she was pregnant with the father being another man. Mr. S. threw her out keeping the two older children. Mrs. S. had done fairly well with the first two pregnancies, delivering full term, normal size, and healthy new-borns. The third pregnancy went very badly. Janie was born at 36 weeks with a weight of 1,900 grams. Other measures were a length of 46 cm and a head circumference of 31 cm. Shortly after delivery, Mrs. S had a cerebral hemorrhage and died. Her maternal aunt who lived in Indianapolis took in Janie.
She had regular pediatric care; weight was gained though she was always on the low end of the growth curves. The pediatrician had little to say except that her head circumference was at the 10th percentile, and she had a doll like appearance with wide set but small eyes, an up turned nose and very thin lips. She had seen these features in many children and at-first was not concerned. Janie was a fussy child and tended to be a bit over active. Developmental landmarks, especially language and socialization were delayed, but no evaluations were attempted until she entered pre- kindergarten. The teacher noticed that Janie was unable to retain information and had a ""Cocktail party personality,"" never holding any conversation to a conclusion or a thought in depth. The parents consulted their pediatrician who took an in-depth history and suggested a developmental evaluation.
Q1. Do these measures suggest anything to you? Can you tie it to the story line?
A1. The characteristic growth of pure prematurely has the weight, length and head circumference at 50% when adjusted for gestational age. These measures put Janie below the 5th percentile for weight and head circumference and relatively normal for length. This is characteristic of in-utero toxicity. Given this history, what might one suspect?
Ask learners to create a listing of possible causes for the growth failure, diminished capacity, facial features, and odd behavior. FAS is only one of many possible causes or perhaps one could say that FAS would co-exist and interact with many other phenomena affecting outcome.
TEACHING CAPTION: One should not assume that developmental and behavioral problems found in a child with a drinking mother are solely related to alcohol exposure in utero.
Fetal alcohol syndrome should come to the top of the list, but it is appropriate to consider all factors and how they might interact with one another. [Link to FAS module] The biologic mother was in a social situation that is highly suggestive of alcoholism. One might have difficulty elucidating a history of maternal drinking from a relative because of the shame involved. One must ask!
The Case continued
You ask Janie's aunt about the possibility that the biologic mother might have drank, smoked tobacco or marijuana, or used drugs. The aunt, who had little to say on this before, said, ""probably all of them. She certainly drank and smoked tobacco. I don't know what else she did."" It was clearly not a conversation she wished to pursue. Her sister's life was a continuous scandal to the family.
Q2. What are the relative risks of drugs, alcohol and tobacco, and how do they affect nutritional status?
A2. Alcohol use and abuse is ubiquitous in society at all levels of social and economic status. Chronic poverty and social dysfunction, such as Janie's mother, creates an environment where sustained use of both legal (tobacco and alcohol) and illegal (marijuana, cocaine, and heroin) addictive, mood altering substances is more likely. Alcohol, tobacco, and other drugs of abuse affect nutritional status in direct relation to duration of use.
Q3. How does this affect pregnancy outcome?
A3. Drug abuse during pregnancy is associated with an increased risk for teratogenesis. As illustrated by studies of alcoholic mothers and children, there is a substantial variability in outcome for children exposed to drugs in utero. [The drug toxicity is discussed more fully in the FAS module]. To an extent that is not yet well determined, maternal nutrition and alcohol intake contribute to these differences. The following table lists four ways in which alcohol exposure in utero might result in deleterious effects.
TEACHING CAPTION: Maternal alcohol consumption affects the fetus differently according to the nutritional status of the mother. Problems accentuate as mothers age. The risk for delivery of an FAS infant increases substantially with parity.
Q4. What is the teratogenesis of FAS?
A4. Berlin, in his review of drugs and teratogenesis describes three possible ways in which a drug can produce birth defects. [ref] The first is a result of direct chromosomal damage. Alcohol in-utero does not have this effect. The second is by affecting organogenesis, and the third is by affecting essential metabolic pathways. Alcohol has these latter effects through pregnancy. Thus its damage will depend greatly on timing as well as dosage.
TEACHING CAPTION: The toxicities of alcohol in-utero are mediated through its affect on organ growth and ongoing metabolic processes.
One hypothesis for the origins of FAS is that alcohol causes renal zinc losses in both mother, fetus, and infant. It has been noticed that the pattern of facial and somatic abnormalities found in FAS resemble those of zinc deficiency. Zinc is essential for protein and DNA synthesis. The finding of increasing urinary excretion of zinc in mothers and infants exposed to alcohol associated with a decreased plasma level strongly implicates a tubular deficit. Alcohol is known for its effect on renal tubules with loss of both magnesium and zinc.
Q5. Are there characteristic developmental outcomes to be seen in children with FAS
A5. As shown in Table 4, the neurodevelopment of children with heavy exposure to alcohol in utero can be described in three categories -- Dysfluency, Failure of executive and poor socialization. [see Streissguth]
TEACHING CAPTION: These findings occur with or with out the dysmorphologies of alcohol. They are present after careful controlling for the social environment after birth.
Note how this pattern matches that provided in the introduction.
First, alcohol, a toxic substance, affects children at a critical phase of development. Second, the behavior of these children affects interactions with parents, peers, and teachers, and third, FAS children experience life (their environment) differently than unaffected children.
Q6. What kinds of interventions are appropriate.
A6. Ann P Streissguth, one of the researchers who recognized FAS in the modern era, writes: ""[A]t all ages the biggest behavioral changes are brought about by proper management of the environment rather than specific treatment of the child."" *
For the infant, notes Streissguth, the needs are for:
1. Protection - There must be careful monitoring of the home situation. Children's protective services are necessary if parental; drinking continues.
2. Nourishment - Failure to thrive is common even with effective parenting because of the poor motor tone of the FAS child. There are often concomitant congenital diseases
3. Stimulation - As with all developmentally ""at-risk"" infants, FAS children require attention to psych-social, language and motor function. This model of social support plus stimulation continues through life. The physician must operate within a setting that provides comprehensive care: Two terminologies for this are:
Figure 2.
In this model, the physician serves as a colleague and a coordinator of services.
Social systems theorist Scott Hedgier has developed a multisystem therapy approach to family intervention. See the module on Failure to Thrive for further discussion.
The older child with FAS should be treated like any other child in the family with appropriate support, affection, and discipline. The most common issue for the family is the concomitant Attention Deficit Hyperactivity Syndrome. The parenting style most affective for these children moves as slowly as they move fast. Problems are never layered as in, ""Janie, after you finish rinsing the dishes, go up stairs and get me your clothes for school tomorrow."" Rather, one provides a task and then affirms its completion with praise. The next request follows, again alone. Career goals must be appropriate and enriching but not highly academic. Help, both counseling and medication will be needed during childhood. It will be necessary to have an Individual Education Plan (IEP) in place in the school setting. While specific nutritional therapy is not effective, being nutritionally deprived or lead poisoned would be quite detrimental to Janie's well being.
1. Streissguth AP. (1986) Fetal alcohol syndrome: an overview and implication for patient management (in) In: Estes NJ, Heinemann ME, Eds. Alcoholism: development, consequences and interventions. St Louis MO: CV Mosby Co. p195-206.
2. Streissguth AP. (1997) Fetal Alcohol Syndrome. Paul H Brookes Publishing Co. Baltimore, MD
The parents: Children with FAS are often placed in the homes of non-alcoholic family members. The presence in the home of an FAS child of an alcoholic child, sister, cousin or aunt may affect family dynamics in two ways. Children like Janie are quite difficult behaviorally and their interacting with siblings, peers, and the school system has multiple potential problems. They may also be a reminder of perceived failure in the family. This can affect the child's nurturing. The case study presentation shows Janise's aunt is quite reticent to discuss her sister's alcoholism. Think of the aunt's life with an alcoholic sister and that of their parents. One must be quite sensitive to the family's desire to literally bury the past, but once confidence is gained, appropriate family guidance is necessary and formal therapy by a mental health professional may be needed. Al-Anon, a family support groups can be quite helpful here.
It is also possible that the child remains in the home of a recovering alcoholic mother or father -- the proper term for an alcoholic who no longer drinks. The stability of the family must be monitored closely though hopefully not intrusively so. Referral to child protective services will be needed if there is continued alcoholism. Many, if not most, recovering alcoholics participate in Alcoholics Anonymous (AA) or a similar program.
The multiple genetic, social, and nutritional factors affecting risk are not likely to change through simple guidance. Rather, a multi-system approach is encouraged for both prevention and treatment of children affected by alcoholism.
A Second Case
Introduction
This case study examines ways that environment and malnutrition interact to produce developmental delay. The impact of malnutrition on intellectual and social development exists in the context of an environment of chronic poverty likely to affect both nutritional status and cognitive development concomitantly. Neither improved social environment nor nutritional status, taken alone, are likely to affect long-term neurodevelopment or school performance. Both are necessary; neither is sufficient.
The case study is not, however, an illustration of the consequences of abuse or neglect. For the most part, malnourished children living in poverty are nurtured and nourished with the same good intentions as children born in advantaged families.
Case #2 Alberto B- A child of poverty with growth retardation, iron deficiency, and a moderately elevated lead level.
Alberto is a 6-year-old patient in the resident clinic. He is the third of four children of a 26-year-old mother who has been pregnant 6 times and has 4 children with two miscarriages. Alberto was born full-term at 2,450 grams. Since birth, however, both growth and cognitive development have been a concern for the health team.
The B family emigrated from Guatemala. Mr. B has dubious immigration status (she won'' tell you that) and may be an undocumented immigrant (an `illegal alien'). The family (mother, father, and four children) lives in Brooklyn, and while her husband has a job, the family finances are not sufficient for food and rent. Mrs. B is very concerned that she has not been able to provide Alberto and his brothers and sisters with enough food. At the end of each month, they send the older children to a family friend to eat one meal each day, and the parents scrimp on their own food. The staff notices that Mrs. B, who is also very short, looks fat. This seems strange to them. ""If she is hungry,"" they ask, ""why is she obese?"" You ask Mrs. B., ""Are you getting food support from WIC?"" She answers ""No tengo WIC; no tengo un `green card.'' [I do not receive WIC; I don't have a 'green card.' I am afraid of the INS."]
Q1. How might this response affect the nutritional status of Alberto and the other children?
A1. Here is an expanded interpretation of Mrs. B's response. "I have not applied for WIC because I am not legally in the U.S., and I am afraid that the Immigration and Naturalization Service (INS) will deport me or deny my application for citizenship if I apply for WIC. I don't know that receiving WIC and Food Stamps are not considered "welfare dependency' " Receipt of welfare benefits would have disqualified her from applying for or receiving citizenship.
Q2. Can you make a connection between poverty and malnutrition?
A2. Let the residents take a stab at this
The consequence of not having sufficient income for food [see Impact of food costs module in Part 2] is two fold. First, as income falls, food selection narrows to those items containing most calories at lowest cost. As time passes, expensive nutrients diminish in the diet. and micronutrient deficiency ensues. In the United States, the two nutrients of most concern are iron and folate. The prenatal folate deficiency is associated with birth defects, prematurity and pre-natal undernutrition and low birth weight (intra Uterine Growth Retardation). At the lowest incomes, there is an increase in children with failure to thrive and growth retardation. These conditions can be accentuated a lack of discretionary income and a need to pay for other necessities such as heat or rent. The persistence of high calorie, low nutrient density foods in the daily diet creates a food culture associated with chronic poverty so that these foods become preferred. An example of this phenomenon is the "fry-bread" consumed by Native Americans from the surplus foods provided - flour and fat. The selections retain even as economic conditions improve.
A second consequence is food insecurity. This phenomenon is further described in Part 2. (Introduction to Food Cost and Culture] When resources waver through the monthly cycle, families tend to concentrate their caloric intact as above and over consume high caloric foods. The nutritional impact of increased obesity for children families living between one and three times the poverty level. Micronutrient deficiencies have been associated in these children also. (Cutts)
Q3. This explains how poverty affects nutritional status. How does nutritional status affect neurodevelopment?
A3. Again, let the residents try. [see modules on iron deficiency and lead poisoning]
Some of the effects are direct such as the impact of iron on CNS function at critical phases of development. Others are indirect such as folate influence on gestation and birth weight with these in turn requiring appropriate responses which may not be available because of limited awareness of need or availability of resources. These later phenomena illustrate the "unique to poverty" impact of malnutrition in learning failures.
Exposure of the fetus to either toxic substances or an experience of malnutrition will have a direct"programmed" impact on the infant at birth (A1) with both direct (----) and indirect ("dynamic" effects (- - - -) on the child at older ages. The direct effects will be mediated through inertia. That is, past successes or failures predict what happens in the present and the present affects the future. At each age, however, the psychosocial environment, including nutritional and psychosocial interventions, will influence outcome concomitantly with pre and post natal influences.
FIGURE 3.
CAPTION: Note that a toxic exposure in utero or in early life will have both direct effects (d) as well as indirect ones (i). Affected older children will react differently to their environment than unaffected ones. This illustrates Wachs' concept of oraganismic-environmental specificity.
A trajectory of development and the "Tilted funnel"
The dynamic of development and the ways in which a child interacts with society will have a profound affect on the trajectory of development. That is nutrition, social environment, and experience in the past and present will have an impact on what is found in the future.
FIGURE 4.
CAPTION: The probability of success or failure in the future is derived from the cumulative experience of success or failure of the past. Note the "tilted funnel" effect.
As described by Ernesto Pollitt, a trajectory for achievement in life is predicted, though not determined, by these experiences. (J Nutr 2000 Feb; 130: 350s-353) With optimal origins, the trajectory of development in-utero will be high with ready achievement of developmental milestones. Within this hypothetically ideal environment, a stronger base is provided for a new born who is fortunate enough to have a no-risk pregnancy than would be provided for an infant born after a problematic pregnancy affected by hypertension, nutrient deficiency, lead or alcohol exposure. Infants encountering multiple risks during pregnancy reach developmental milestones at older ages. Expectations diminish along with achievement.
Similarly, the trajectory of development during the first year of life for a privileged child will be high. There will be a stronger foundation for future success for a one year old with good nutrition, no exposure to toxins and responsive, sensitive, stimulating parents. This child will reach a higher level of development than the toddler with a problematic first year characterized by undernutrition, lead poisoning or unresponsive, insensitive or unstimulating parents. Simply stated, the probability of future success builds upon past success and the probability of future failure builds upon past failure. As stated in a report from the National Research Council Institute of Medicine,
"Deficits in brain growth and central nervous system development resulting from early malnutrition can compromise early learning, which can then become a risk for decreased economic opportunities and poverty." (30)
The fourth grade crises and the "titled funnel"
The educators ED Hirsch, Jr and Jean Schall describe this phenomenon the fourth grade plunge (Hirsch) and the "tilted funnel (Schall)." A crisis in development occurs in the fourth grade when children who have not developed the ability to process information fail in school. Higher levels of cognitive function are expected. No longer do children read to demonstrate an ability to decode symbols and say words. They must read to learn: to obtain information, process that information, and apply it to accomplishing a task. Similarly, children must have their numeric abilities in place to process mathematical information and use it to solve problems. The most complex challenge for the 9 and 10-year-old children in fourth grade is the mathematics problem with information provided in words. The processing must cross boundaries of past learning. Success in early childhood intervention can only be assumed when the fourth grade "ceiling" is passed.
See Hirsch ED. The Fourth-Grade Plunge: the cause, the cure. American Educator. 2003, vol 27. With articles by Drs Hirsch, Hart, Risley, and Schall describing the "tilted funnel" effect.
See also Ramey CT, Campbell FA. (1992) Poverty, early childhood education, and academic competence: The ABECEDARIAN project. In: Huston C, ed. Children in Poverty. New York: Cambridge University Press. Dr. Ramey documents programs beginning prenatally and continuing through early school age that meet Dr. Hirsch's challenge.
Q4. What are specific effects of iron deficiency, growth retardation, and hunger on neurodevelopment?
A4. Iron deficiency.
The late Frank Oski was among the first to suggest that learning problems associated with iron deficiency were mediated by lack of iron availability for the formation of specific structures and/or key enzyme systems in the central nervous system (CNS) mono amine and cytochrome oxidase. His case-controlled studies of children from impoverished north central Philadelphia found that intellectual performance was directly linked to iron status after controlling for other factors.
An alternative theory is that neurotransmitter activity in the central nervous system operates in parallel with the severity of iron deficiency -- the decease in hemoglobin levels. (See Lozoff and Karp in Malnourished Children in the United States)
In this later model, learning failure occurs only in the last phase of iron deficiency in the presence of anemia. Inability to transport oxygen limits a child's ability to sustain motor activity, which is critical for learning by exploration and repetition.
Wilkins and Pollitt, in their 1998 publication from the Pan American health Organization publication, ask three questions that help elucidate the dilemma
1. Does iron deficiency anemia in infancy affect cognitive function later in life? The answer is an uncontroversial "yes." Lozoff's Costa Rican studies show children who were anemic continue to have decreased cognitive function later in life even after the iron deficiency was corrected. the data was adjusted for social and economic differences
2. Does current iron deficiency anemia affect cognition? Here the results are equivocal. In Karp's Philadelphia studies, there were profound parenting differences in families of children with iron deficiency anemia. In theory, the impact of anemia on oxygen carrying capacity would affect an ability to sustain activity. This would in turn affect interactions and an ability to learn. The Latin American studies suggest that differences on cognition are likely only if the anemia is severe and of long duration.
3. Does iron deficiency without anemia affect cognition? The hypothetical model holds appeal and there are data supporting this position. The likelihood that a child will go though the phase of iron depletion n and become anemic is apparent.
This material is consistent with the model shown in Figure 3. Iron deficiency has a direct toxic effect as well as indirect ones.
Q5. How does growth retardation, as seen in the United States, affect intellectual functioning?
A5. Mild to moderate malnutrition associated with chronic illnesses such as cystic fibrosis does not have a demonstrable impact on intellectual development when the child is in a supportive environment. In the context of an impoverished environment, however, there is an association between the physical growth and neurodevelopment.
Studies at an the Pratt-Arnold elementary school in north central Philadelphia elementary school showed that children with decreased height-for-age (stunting) were older than their classmates. (see Karp, 1999) This reflected delayed entry into school, one of several indicators of ineffective nurturing likely to diminish both school performance and nutritional status [i]. The undernourished children appeared to be of "normal" size and performance by grade (but not by age) when compared to their younger classmates. These children were not entered into school at appropriate age raising the question of whether a common antecedent parenting factor affected both development and nutrition concomitantly. Looking younger than their chronological age, note Brown and Pollitt would cause adults "to treat them as if they were younger than their actual age. Such a response would very likely slow cognitive development." As in developing countries, these stunted children seem normal for their height age because of the close parallel between height age and social and intellectual development. Yet they are retarded when compared with well nourished children of the same age.
The growth-retarded children at the school had measures of perception and motor development that reflected height-age better than chronological age. Their height-age correlated with reading level when there was associated anemia or muscle wasting. With normal hemoglobin level and muscle mass, height and reading level were unrelated suggesting the influence of undernutrition associated short stature on learning. As Pollitt notes, the impact of various nutritional deprivations (linear growth, weight, anemia, muscle mass) occurring together is more important than an individual nutritional deprivation acting alone.
At Pratt-Arnold, measures were taken of nutritional status, cognitive function, and neuro-development, along with a composite measure of school achievement. Using step-wise regression (age factored out), the data demonstrated that gradations in all anthropometric measures were significantly related to rising achievement scores, but anthropometric variables correlated better with academic achievement than with measures of cognitive ability or neuro-development. This suggests that there are common antecedents of undernutrition and learning failure -- the cluster effects of poverty and consequence of failed mother/child interaction -- affecting school achievement. Thus, for undernourished children, growth, nonverbal aspects of neurodevelopment and learning seem to be on a "slow track." These findings provides explanation, in part, as to why undernourished children who have been adopted into homes where they are well fed and well nurtured are better achievers in school even when growth continues to be somewhat slow.
Q6. How does hunger affect learning?
A6. Because hunger is not a form of malnutrition, measures of nutritional status may be normal. A well-nourished child will have sufficient glycogen stores to maintain blood glucose levels for an overnight fast. During periods of fasting, there is a switch in metabolism to ketones produced in the liver, but this switch is not activated quickly. Thus, without early-morning glucose provision, the brain may not function effectively.
In studies in Jamaica, Simeon and Grantham-McGregor showed the synergism between missing breakfast and prior malnutrition on skills in language fluency, performing arithmetic tasks, and maintaining short- and long-term memory. (Am J Clin Nutrition, 1989;49:646-53). The figures below show an association between problems likely to lead to learning failure and breakfast deprivation in children with prior malnutrition. As they write, "The control group was not adversely affected in any of the cognitive tests when breakfast was omitted.... In contrast, the previously malnourished and the stunted groups were adversely affected in fluency (a measure of generation of ideas and motivation) and coding (visual short-term memory). Relative to the control children they were also adversely affected in arithmetic."
The well-nourished children seemed less affected. The study is unique in that it delineates a group of children who had a history of malnutrition. The authors suggest that the nutritional deprivation had affected the state of central nervous system arousal required for the children to achieve in learning situations.
"Clearly," they write, "the association is complex and performance depends not only on the state of arousal but also on the type and difficulty of the task and the nature of the subjects. It is possible that malnourished children have levels of arousal different from those of control children ... missing breakfast could be a serious contributor to poor school achievement in undernourished children.... School meals could be targeted to undernourished children."
Recent studies by Pollitt confirm the observations by Granthum-McGregor(see PAHO monograph, pp119-127.
FIGURE 5.
Although the stated purpose of the school breakfast program is to prevent the consequences of hunger, a second associated benefit is improved attendance. The results of a study of school breakfast program participation in an industrial suburb of Boston showed "improvements in achievement test scores, absence and tardiness" rates of participating as compared with nonparticipating children, with the data evaluation controlled for sex, ethnicity, grade in school and preschool breakfast test scores, and absence and tardiness rates .
Meyers, et al Am J Dis Child. 1989;143: 1234-1239.
Q7. How do nutrition and environment interact to affect learning?
A7. Unless parents living in poverty are taught how to respond to the special needs of malnourished children, the children's learning and nutrition will continue to cycle downward. Working with poor children in Providence, Rhode Island, Sameroff and Chandler (67) recognized that the variability in outcome of birth weight in medically compromised infants was a function of the "cluster effects" of multiple consequences of poverty. The transactional model for learning described below derives from their work.
Thus the effects of malnutrition must always be considered in the context of the particular social environment with or without evidence of direct toxic consequences of malnutrition. Ineffective relationships within families and between parents and children affect the growth of poor children. Other family members are frequently undernourished. The pattern of single parenthood without a support system is common. Though, as with the B family, fathers are often in the home, or there are extended family networks that provide support. Medical, social and educational resources are often inadequately available and used. The B family's dilemma is common with immigrant families. Other examples include the treatment of uninsured families. Delayed entry into school and poor attendance are likely. Often, the reduced somatic growth used to define malnutrition reflects the concomitant effects of iron and zinc deficiency, inadequate caloric intake, exposure to lead, and to alcohol and drugs in-utero.
Case 2 continues - (development)
Alberto has recently begun kindergarten, but he has been reported as being slower than the other children. Mrs. B brings a report card that says "Alberto is inattentive and has difficulty with fine motor tasks. He can not hold a pencil properly to write his letters." Mrs. B brings the report card in for your help as she is not sure what this means. She expresses concerns about the health of her youngest child, Elisabeth, a 6-month-old girl. She asks if Elisabeth will have the same problems in school.
Q8. How do these fit together? That is, can we diagram the impact of poverty and possible malnutrition on Alberto's intellectual development?
A8.
1. Children at risk for malnutrition are more likely to benefit if nutritional supplementation is provided in an enriched social environment. Combined interventions are significantly better than single interventions.
2. The intervention must be provided over a long period of time with successive adaptations to Alberto's changing development.
3. One must also consider the nutrition, health and behavior of the parents. They should be included in a step wise manner giving information when it is necessary and meaningful to them, Pay attention to the interaction between child and care -giver.
And a listing for Alberto describing his past experience:
1. There is a high risk social environment simply because they are poor. This will affect both the social milieu and the nutritional status.
2. The social environment at home is overwhelmed by the presence of four young children in a home with a young mother and a barely present overworked father.
3. The income poverty has lead to diminished nutrient intake as described and iron deficiency
4. Other factors, both those they can't control (macrosocial = INS policy towards health and nutrition benefits) and those they can (microsocial = Mom's response to fear of INS) have kept her from applying for WIC though she is eligible without fear and doesn't know it. In addition, having many children at a young age, linguistic limitations in her native language may also affect development
5. Her use of services that might have helped her are limited out of her inability to use them or their lack of accessibility, or both.
6. The undernutrition and lack of enrichment affect the child at critical/sensitive phases of development.
7. Alberto is a listless learner and does not stimulate teaching
8. Alberto experiences the new and enriched environment of the public preschool unprepared to appreciate or use the resources effectively.
Q9. And what can be done for Alberto, now?
A9. A multi-systems approach is necessary. Even though, the impact of iron deficiency and growth retardation seems leave a permanent deficit in intellectual functioning, there is much to be gained from providing the B family and Alberto with support. A listing would be as follows:
1. Work with the B family to endure an adequate support for food through use of food programs.
2. Get help from legal services to put their immigration papers is order.
3. Provide medical therapy for iron deficiency [Link to module]
4. Give guidance of exercise and diet for Alberto's obesity
5. Provide care for Elisabeth and the other children too. Think "prevention."
6. Refer to an educational enrichment program for testing and support for Alberto. While Developmental scores are unlikely to be affected, how Alberto approaches his work and uses his skills are amenable to therapy.
7. Continue to support the B family within your Medical Home. As Dr. Sia and the American Academy of pediatrics suggest provide the full panoply of services available to children and families.
Summary: Putting these cases together:
Simply addressing undernutrition (iron deficiency and/or growth retardation) or alcohol in-utero or lead poisoning alone without a multi-system approach to intervention is a certain prescription for failure. As the National Research Council reports,
"The longstanding debate about the importance of nature versus nurture, considered as independent influences, is overly simplistic and scientifically obsolete.....The important questions now concern how environments influence the expression of genes and how genetic makeup, combined with children's previous experiences, affects their ongoing interactions with their environments during the early years and beyond."
Each of these cases illustrate that nutrition is a necessary but not sufficient contributor to learning. Malnutrition among the poor in developed countries usually occurs in social environments that affect both nutritional status and learning ability synergistically. Figure 6, showing an Ecology of Poverty, Undernutrition and Learning Failure, suggests that learning failure is contingent on an interaction between social environment and nutrition. Giving food and micronutrients to the nutritionally and socially deprived child without correcting the environment in which the undernutrition occurred is unlikely in the long run to change greatly anything related to learning. Rather, the combination of social and nutritional intervention is more effective than either social or nutritional interventions taken alone [ii].
FIGURE 6.
CAPTION: In developed countries, the prevalence and consequences of malnutrition in young children are related so closely to chronic poverty that one can only rarely distinguish the consequences of these disorders from the consequences of living in the milieu in which undernutrition occurs.
No single environmental influence creates the conditions that make continued poverty inevitable. rather, it is the synergism among these influences that keeps affected children from escaping the cycle of poverty. In this figure, care was taken to make indirect rather than direct connections between poverty and effective parenting and learning failure in the child. Ineffective, neglectful or abusive parenting coupled with drug and alcohol abuse is found at all levels of society, but the poor parents lack education and social support. That lack interferes with their abilities as parents. When poverty combines with problems not directly related to poverty (child abuse, drug and alcohol abuse), the consequences to a child's ability to learn are amplified. Moreover, there are effects of poverty that are directly related to learning failure. These are: lack of parental education, inadequate diet, and exposure to lead in the environment. One must also consider the generally poor quality of the early childhood education and schools that serve these children, and the impact of that educational experience on learning
SUMMARY: From Principles to Practice
These two cases provide a small window into the world of malnourished children as might be seen in the United States. Other examples would be children adopted after an experience with malnutrition in infancy or others with iodine missing from their diet. While these would have different histories and different outcomes, the principles of care are the same. The common circumstance is that poverty and malnutrition intersect at a critical time in the life of an affected child.
Elements associated with living in poverty in the United States - malnutrition, learning failure, lack of social support, poor self-esteem, and dysfunctional or ineffective parental behavior feed upon themselves to regenerate poverty, from one generation to the next. Iron deficiency and growth retardation in childhood affect both learning and behavior. Simply addressing undernutrition (iron deficiency and/or growth retardation), alcohol in utero or lead poisoning alone, however, without a multi-system approach to intervention is a certain prescription for failure. As the National Research Council reports,
"The longstanding debate about the importance of nature versus nurture, considered as independent influences, is overly simplistic and scientifically obsolete.....The important questions now concern how environments influence the expression of genes and how genetic makeup, combined with children's previous experiences, affects their ongoing interactions with their environments during the early years and beyond."
The key then is to determine the elements of prevention at the place where poverty, malnutrition, and developmental delay intersect. It is essential to address the macro-social needs (what goes on outside the experience of an "at-risk" child) if there is to be an expectation that micro-social issues (what goes on within the community and family)are to be resolved Recognize elements in the "macrosocial" environment that might provide resources likely to contribute to an equality of opportunity for all children. These include insuring the availability of health care and support for affordable culturally acceptable nutritious food. Provide resources for parents and children geared to improve child development.. Inadequate income [income poverty] sets in place all of the elements of social dysfunction associated with living in chronic poverty.
Similarly, at the "microsocial level, the most effective programs are preventive. It is essential ton address the interactions between children and everyone and everything in their reach . This means working with children and families one at a time using the following eight principles.
References
Salisberry PJ. Reagan PB Dynamics of Early Childhood overweight. Pediatrics 2005;116:1329-38
Watkins WE, Pollitt E. Iron Deficiency and cognition among school age children (in)Pan American Health Organization. (1998) Nutrition , Health, and Child development. Scientific Publication No. 566pp. 179-97
Grantham-McGregor S, Walker S. Health and Nutritional Determinants of school failure. (in) op cit. pp 82-90
Grantham-McGregor S. Introduction in, etc pp vii
Grantham-McGregor S Summary. In pp. 256-257.
Streissguth AP.(1997) Fetal Alcohol Syndrome. Paul H Brookes Publishing Co. Baltimore, MD
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- i In these school studies, malnourished children were more likely to live on numbered (long-running, with heavy traffic, no trees and deteriorated housing) rather than named (short-running, with little traffic and tree lined) streets. These differences in condition of housing stock and quality of life on the streets of north central Philadelphia reflect the interaction between undernutrition and the environment that produces it. Stable employed families chose to live on named streets. They provided more effective nourishment and nurturing, too.
- ii Seeming exceptions: Iodine supplementation for populations and especially pregnant women will prevent cretinism. This is accomplished by fortifying table salt while insisting that there not be a price difference. Indirectly, folate supplementation of commercially used flour accomplishes a similar task. Birth weights are higher and there are fewer cases of neural tube deficit in folate replete populations. Nevertheless, once the defect occurs (Prenatal in Figure X), the outcome sets in motion a series of events whereby the developmental delay affects subsequent generations of children.
Annotated Pre-test Answers
A1. The answer is false. The principle message of this module is that correcting nutritional deficiencies is necessary but not sufficient when addressing the developmental effects of malnutrition.
A2. The answer is c. Alcohol Related Birth Defects are not necessarily recognizable. The concept of Fetal Alcohol Effects (FAE) has been used to describe the developmental problems of children not showing the FAS dysmnorphology. And, of course, growing up with one or the other parent as an alcoholic will affect development. You knew that.
A3. The answer is True. This is an operational expression (what actually happens) of the principle message.
A4. The answer is false. Lead poisoning and iron deficiency have several points of interaction including enhanced absorption of lead with iron deficiency and interacting developmental and behavioral consequences.
