899 that alteration in the bowel flora produced by cow’s milk favours the development of allergy to other antigens and that avoidance of foreign antigens by prolonged breast feeding may reduce the prevalence of asthma as well as eczema. Department of Child Health, University of the West Indies, Mona, Kingston 7, Jamaica
P. S. E. G. HARLAND VICTOR LIZARAGA
STIMULATION AND MENTAL DEVELOPMENT OF MALNOURISHED INFANTS
SiR,-Dr Grantham-McGregor and colleagues (July 28, p. found a significant increase in mental development when stimulation was added to the dietary and medical management of severely malnourished children. This effect has been reported by others,I,2 and the table, which is a summary of our data, shows that 7 out of every 10 severely malnourished infants of less than 6 months of age catch up in mental development (i.e., the slopes for the relation between mental development and days of life were greater than 1-0) in all four areas of the Gesell test when stimulation is systematically given in the hospital ward. In contrast, only 3 out of every 10 infants with similar degrees of intensity and duration of malnutrition catch up with their well-nourished peers in the same ethnic and socioeconomic groups, when no systematic stimulation is added to their treatment. What surprises us about Grantham-McGregor’s letter is that a one hour per week visit by a community health worker, who encouraged the mothers to play with their children using
200)
6 months of age could not have been influenced by knowledge of the child’s nutritional history for that history was yet to be written, only 1 child having symptoms by that time. The predictive value of the scores on home stimulation are now being used to guide the selection of families for primary prevention of severe malnutrition. Very similar data on the presence of a low stimulation environment and future malnutrition have been reported by Richardson.5 Moreover, in studying the quality of mother-child interaction in our longitudinal cohort, we found that the pattern of the mother’s behavioural responses in a test situation allowed the identification of different styles of child care within the families having a child at high risk of developing severe malnutrition, and strongly suggested that severe malnutrition among children in the families at high risk is associated with an inadequate microenvironat
ment.
A low level of home stimulation and a passive, traditional unaware of the needs of her child and responding to him poorly as if unable to decode his signals, are characteristic features of this poor microenvironment that lead to severe clinical malnutrition in children of poor families.6 A follow-up study of children less than 6 months old with or without added systematic stimulation during their treatment for severe malnutrition showed that their growth and mental development after discharge from the ward was in direct relation to both the stimulation quality of the home microenvironment and the quality of the mother-child interaction. Mental scores and physical measurements were independent of whether stimulation was provided during their hospital
mother,
stay or not. EVOLUTION OF MENTAL DEVELOPMENT AS A FUNCTION OF AGE, DURING NUTRITIONAL REHABILITATION OF YOUNG INFANTS WITH AND WITHOUT ADDED SYSTEMATIC STIMULATION
It might be that Jamaican mothers and severely malnourished infants are very different from Mexicans, though Richardson’s dataon the life histories of a group of malnourished infants extracted from among admissions to the same unit as the one from which the children studied by GranthamMcGregor et al.came do not point in this direction. a full description of the microenvironments of the children and their mothers could help us in explaining our clearly contradictory findings. It may well be that in certain microenviron,ments it is enough for the maintenance of mental recovery in hospital, simply to encourage the mother to play with her rehabilitated child. Every child admitted to hospital, for whatever reason, should be stimulated, but before we accept that with this procedure mental recovery in severely malnourished infants would be accomplished and sustained after discharge, more detailed information is needed.
Perhaps
toys made from discarded household materials, was enough to sustain the levels of mental performance reached in the hospital by the stimulated group, while the adequately nourished group lost 10 DQ Griffiths’ points during the year of observation. In a longitudinal study of the total number of children born alive in a calendar year in a typical large village of Central Mexico, we identified 19 with severe clinical malnutrition at some time before 39 months of age, most cases being between the ages of 1 and 3. As part of the research on the entire cohort of children Caldwell’s inventory of home stimulation3 was administered twice yearly up to age 3 and then yearly thereafter. The distribution of scores of the stimulation inventory was markedly different between index cases of malnutrition and controls extracted from the same birth cohort. At 6 months of age, at which time only 1 clinical case of severe malnutrition had appeared, the index children were living in homes low in stimulation and support for development. At all ages after rehabilitation the picture was the same: the children who had had severe malnutrition continued to live in less stimulating homes than did the control children.4 The results 1. Yatkin
US, McLaren DS. The behavioural development of infants recovering from severe malnutrition. J Mental Def Res 1970; 14: 25. 2. Cravioto J. Not by bread alone: effects of early malnutrition and stimuli deprivation on mental development. In: Ghai OP, ed: Perspectives in pediatrics. New Delhi: India Interprint Metha House, 1977: 87-104. 3. Caldwell BM. Descriptive evaluation of child development and of developmental settings. Pediatrics 1967; 40:46. 4. Cravioto J, DeLicardie ER. Environmental correlates of severe clinical malnutrition and language development in survivors of kwashiorkor and asmus. Boletin Ofic Sanit Panam (English ed) 1973; 7: 50.
mar-
Instituto Nacional de Ciencias y Tecnologia de la Salud del Niño-DIF, Sistema Nacional para el Desarrollo Integral de la Familia, Mexico City 22, Mexico
J. CRAVIOTO R. ARRIETA
RETINOL-BINDING PROTEIN IN MALNUTRITION p.
SIR,-Dr Shetty, Dr Schwant, and their colleagues (Aug. 4, 230; Oct. 13, p. 794) have shown that plasma concentra-
tions of retinol-binding protein (RBP) and thyroxine-binding prealbumin (TBPA) fall when recent intakes of protein or energy have been low. Plasma albumin concentrations were much less sensitive to dietary change. These findings are not controversial, but their interpretation could be when it is un5. Richardson SA. Ecology of malnutrition: nonnutritional factors influencing intellectual and behavioural development. In: Nutrition, the nervous system and behavior (Pan Am Health Org Sci Publ no 251). Pan American Health Organisation, 1972: 101. 6. Cravioto J, DeLicardie ER. Mother-infant relationship prior to the development of clinical severe malnutrition in the child. In: White L, Selvey N, eds. Proc. VI Western Hemisphere Nutrition Congress, Bal Harbour, Florida. 1974: 126. 7. Richardson SA. The relation of severe malnutrition in infancy to the intelligence of school children with differing life histories. Pediat Res. 1976; 10: 57.