the population of underdeveloped countries is below the age of 15 years Table 1 Age structures in developed countries'9 and developing Country group
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the population of underdeveloped countries is below the age of 15 years Table 1 Age structures in developed countries'9 and developing Country group
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Currenttopic
KCONNOLLY
resourcesareoftengrosslyunevenlydistributed;wheremalnutritionisoftenendemic;childhooddiseaserife;andwheresurvivalisthefirstgoal.Thebulkoftheworld'schildrenareinthedevelopingcountries,andthelargestnumberareinthelowincomecountries.Inthepast35yearstheworld'spopulationhasalmostdoubled,andthatgrowthhasbeenlargelyconcentratedinthe de-velopingcountrieswhereitisnowabout2%per
mostpartpeopleareunabletotakeadvantageofopportunitiesthatmayoccur.In thesecircum-stances,thefamilydoesnotcherishchildhoodasaprolongedandespeciallyprotectedstageinthelifecycle.Theyounghavealltoosoontodobattlewiththeirenvironmentinordertomaintainevenamarginalposition.Itishardlysurprisingthatachildgrowingupinsuchaculturehasstrongfeelingsoffatalism,helplessness,dependency,andinferiority.Acentralfeatureofscienceisdevelopingmethodsofdescribingandmeasuringthevariablesthatareof
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Health
2647321710171646320
692042192190
1157513537341444870
8521
685541Middleinfantmortalitycountries
402697056675210291770
9150908551Lowinfantmortalitycountries
11(.)74
908592706-4149110
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882Connolly
Malnutrition
Theeffectsofdiseasearecompoundedbymalnutri-tion.Forthemostpartmalnutritionisinvisible.Thesickeningconsequencesoffaminethatwehavegrownusedtoseeingonourtelevisionscreensaccountforlessthan2%ofthecasesofmalnutri-tion.In1981,itwasestimatedthat40000childrendiedeachdayfrommalnutrition,andforeverydeathmanymorechildrenclingtoadebilitatedlifeinhunger.Asimpleanswertomalnutritionistoprovidefood,butitismorecomplicatedthanthatandweneedtounderstandbetterboththecausesandconsequencesofmalnutrition.Malnutritionreducesresistancetoinfection,andinfectionoftenprecipitatesmalnutrition-andsothetworeinforceeachother.Wherethesequencesofmalnutritionanddiseasearerapid,deathresults;wheretheyaresloweddown,thechildrenendureseriousdevelopmentaldisadvantage.Theconse-quencesofmildtomoderatemalnutritionaredifficulttoinvestigatebecauseoftheconfoundingofbiologicalandsocialfactors.Gradually,evidenceisaccumulatingthatshowstheeffectsonmentalandbehaviouraldevelopment.5Malnutritionhascon-sequencesonaninfant'slevelofactivity,explora-torybehaviour,andsocialinteraction.Apathyreducesthechild'sphysicalandsocialtransactionswiththeenvironment.Otherconsequencesmaybemediatedbyadults.Achildmayfailtoevokefromthemotheradequatestimulation,sensitivecaring,orthenecessaryencouragementfordevelopment.Betternourishedinfantsareseenbyparentsasmoredemanding,andgreateractivityonthepartof thechildincreasesparentalpleasure.6Malnutritionthereforehasmorethanonerouteofaction.Severemalnutritionmayhaveaprimarilyphysiologicalroutewhereaslessseverecasesmayhavetheireffectlargelyviathechild'sreducedcontactwithhisphysicalandsocialworld.Specificnutritionaldeficitsalsohaveeffects.Forexample,iodinede-ficiency,whichiscommoninmanyoftheunder-developedcountries,especiallythoseinmountain-ousregionsoftheworld,isknowntohavecon-sequencesonthebehaviouraldevelopmentofchildren.78Anyinvestigationofbehaviouralmediationonthedynamicsofnutritionaldeficitrequirescarefulattentiontothepatternofcaretakingbecauseweneedtounderstandthecontextualmechanismsofearlydevelopment.Superetal,9inacarefullydesignedinterventionexperimentamongpoorfam-iliesinthebarriosofBogota,haveshownthatnutritionalsupplementsandamaternaltrainingprogrammehaveeffects,separatelyandinconcert,onthebehaviouraldevelopmentofinfants.Thesefindingsdonotfiteasilywithsomeofourearlierideasbuttheyareintuitivelyplausible,andsowemustlooktoourtheoriesandmodelsofdevelop-ment.AsIhavesaid,animportantfeatureofscienceismeasurement.Whenavariablecanbeidentifiedandmeasureditbecomespossibletostudytheeffectsofexperimentalmanipulations,therapeutictreatments,educationalprogrammes,andsoforth.Animportantstepincombatingmalnutritionisitsearlydetectionandmeasurement,andasimple,reliablemethodisavailable.Bysystematicallyweighinginfantsandplottingweightchangesonagrowthchartitispossibletodetectearlysignsofmalnutrition.1011Anearlywarningalertsmotherstotheneedforactionwhetheritbesupplementaryfeedingorgettingmedicalaid.TheuseofgrowthchartsisoneofthespearheadsofwhattheUnitedNationsInternationalChildren'sEmergencyFund(UNICEF)hascalledthe'Children'sRevolution'.12Averyimportantfunctionwhichthegrowthchartservesisasameansofeducatingmothersabouttheirchildren,andperhapsmostimportantlyofall,itshowsthemthattheydohavesomecontroloverevents.Oneofthemosteffectivemeansofcombatingearlymalnutritionistobringaboutachangeininfantfeedingpractices.WinstonChurchilloncesaid,inoneofthosefamouswartimebroadcastsofhis,'Therecanbenofinerinvestmentforanycommunitythanputtingmilkintobabies.'Wouldthathehadsaidmothers'milk.Theshiftfrombreasttobottlefeedinghasbeenmassiveanddisastrous.Forexample,inRecife,alargecityinthepoornortheasternregionofBrazil,allbabieswerebreastfedin1940.Bythe1970stheproportionhadfallentolessthan10%.In1975asurveyinPortMoresby,thecapitalofPapuaNewGuinea,found35%ofbabiesbeingartificiallyfedandtwothirdsofthemweremalnourished.Avigorousgovernmentcampaign on July 22, 2023 by guest. Protected by copyright.http://adc.bmj.com/Arch Dis Child: first published as 10.1136/adc.60.9.880 on 1 September 1
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Fertilityandconditionsforchildren
Spacing
interval(years)<2 2-3 4+ I 2-3Birthoader
4-6 7+Mother's
age(years)<20 20-29 30-3940+
050100150Mortalityrate(per1000)
FigureInfantmortalityper1000livebirthsinPeruinrelationtospactlgintervalbetweenbirths,birthorder,andmaternalage.920I on July 22, 2023 by guest. Protected by copyright.http://adc.bmj.com/Arch Dis Child: first published as 10.1136/adc.60.9.880 on 1 September 1
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EducationofwomenChildrenintherecession
CountryYearsofschooling
None1-34-67-J10+
Paraguay197210480614527CostaRica197312598705133Columbia197312695634232Chile1970131108926646DominicanRep.197517213(010)68154Ecuador19741761341()I6146ElSalvador19711581421119830)Bolivia197524520917611(Theworldisexperiencingtheworstrecessionin50years.Forthemostpart,governmentsandotheragencieshavebeenpreoccupiedwithnarrowlyeconomicissues-inflation,interestrates,tradedeficits,andthelike.Butwhathastherecessiondonetochildren?Overthepast40yearschildwelfarehasimprovedgreatlyindevelopedanddevelopingcountriesalikebuttherearestillgreatdifferences.Theeffectsofrecessiondependamongotherthingsonthepositionfromwhichpeoplestart.Becauseofitseconomicandhumanresourcesonefamilymaybewellbufferedagainsttheeffectsofrecession.Anothermaybesopoorthatitishardlytouchedbythechanges-toopooryoumightsaytohaveaccesstotheworldcrisis.Differentregionsandsocialgroupsareaffecteddifferentlyandcountrieshavere-spondedinvariouswaystothecrisis.Somehavecutbackonsocialservices,othershaveacceleratedtheirdevelopment,yetothershaveconcentratedtheirresourcesintoparticularareasofsocialwelfare.ThecountriesofAfricaseemtohavesufferedthemostseveresetbacks,whileSouthEastAsiancountrieshavewithstoodtheworsteffectswithonlyminordislocations.AseriesofcasestudiescommissionedbyUNICEF'7hasexaminedtheeffectsofrecessiononchildrenfromcountriesinSouthAmerica,Africa,Asia,NorthAmerica,andEurope.Thepicturethatemergesislimitedbytheavailabilityofreliableanduseful data.Alsoitisimportanttoappreciatethatthereiswidespreadlackofinforma-tionabouttheconditionofchildreninthepoorestcountries.Tospeakofchildwelfareimpliesthatthereisgeneralagreementonwhatitis,onitsmaindeterminants,andontheindicatorsappropriatetoassessitslevel.Cornia'8hasoutlinedaschemeoftheproductionofchildwelfarethatillustratestheroutebywhichinternationaleconomiceventscon-tributetochangesinthesituationofchildren.Three2classesofvariablesexertadirecteffect.Firstthefamilyandcommunity:thesedetermineachild'sphysical,social,culturalandpsychologicalenviron-ment,andIhavealreadystressedtheimportanceofmaternaleducation.Thesecondishouseholdin-come,whetherincashorinkind.Incomegivesaccesstofood,clothing,housing,andinsomecountrieseducationandhealthservices.Asuddensharpdeclinewillhavepredictableeffects.Thethirdsourceofinfluenceisgovernmentexpenditureonsocialservices(includinghealthandeducation).Theseservicesareusuallypaidforbytaxes.Ifrevenuesfallsoexpendituremustbeadjusted,cutsbecomeinevitable,andasweknowfromtheBritish on July 22, 2023 by guest. Protected by copyright.http://adc.bmj.com/Arch Dis Child: first published as 10.1136/adc.60.9.880 on 1 September 1
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Conclusions
References
2Miles1.Socialindicatorsfromhumandevelopment.London:FranicsPinter,1985.3YoungFE,EdmonstonB,AndesN.Communityleveldetermi-nants ofinfantandchildmortalityinPeru.SocialIndicatorsResearch1983;12:65-81.4KvalsvigJD.Theeffectsofschistosomiasisonspontaneousplayactivityinblackschoolchildreninendemicareas.SAfrMedJ1981;60:61-4.5JoosSK,PollittE,MuellerWH,AlbrightDL.TheBaconChowstudy:maternalnutritionalsupplementationandinfantbe-haviouraldevelopment.ChildDev1983;54:669-76."ChavezA,MartinezC,YaschineT.Theimportanceofnutritionandstimulionchildmentalandsocialdevelopment.In:CiaviotoJ,HambraensL,VahlquistB,eds.Earlymalnutritionandmentaldevelopment.Stockholm:AlmqvistandWiksell,1974.7ConnollyKJ,PharoahPOD,HetzelBS.Fctaliodinedeficiencyandmotorperformanceduringchildhood.Lancet1979;ii:1149-51.PharoahPOD,ConnollyKJ,EkinsRP,HardingAG.Maternalthyroidhormonelevelsinpregnancyandthesubsequentcognitiveandmotorperformanceofthechildren.ClinEndocri-nol1984;21:265-70.9SuperCM,ClementJ,VuoriL,etal.InfantandcaretakerbehaviourasmediatorsofnutritionalandsocialinterventionintheBarriosofBogota.In:FieldTM,SostekAM,VletzeP,LcidermanPH,eds.Cultureandearlyinteractions.Hillsdale,NcwJcrscy:Erlbaum,1981.MoricyD,WoodlandM.Seehowtheygrow.London:Mac-millan,1979.TremlettG,LovelH,MorleyD.Guidelinesforthedesignofnationalweight-for-agegrowthcharts.AssignmentChildren1983;61/2:143-75.12GrantJP.Thestateoftheworld'schildren1984.London:OxfordUniversityPress,1983.3SantowG,BracherMD.ChilddeathandtimetonextbirthincentralJava.PopulationStudies1984;38:241-53. on July 22, 2023 by guest. Protected by copyright.http://adc.bmj.com/Arch Dis Child: first published as 10.1136/adc.60.9.880 on 1 September 1
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CorrespondencetoProfessorKConnolly,DepartmentofPsy-chology,UniversityofSheffield,SheffieldS1O2TN. on July 22, 2023 by guest. Protected by copyright.http://adc.bmj.com/Arch Dis Child: first published as 10.1136/adc.60.9.880 on 1 September 1