Leary, P.M.

Lewis, J.E.S.

English

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1156N 90S.A. MEDICAL JOURNAL(Sl/pplemenT - Sowh African 1ol/fIlIII of NI/TriTion)18 December 1965ouers beteken dit-hier is 'n dokter wat ons aanvaar,,mislukkings en al'.KIf'.'OERS MET EETPROBLEME GESIEN BY DIE KINDERPSIGIATRIESEKLINIEK VAN DIE PRETORIASE ALGEMENE HOSPITAAL, VANAF 1JANUARIE 1961 TOT 31 DESEMBER 19641. lnsidensie. By 27 uit 'n totaal van 350 pasiente wat gesienis, was 'n eetprobleem die hoofstoornis. Dit sluit nie gevaJlein waar ouers alleen by verdere navraag gemeld het dat diekind 'n eetprobleem het nie.2. Ceslag. 12 seuns en 15 dogters.( Bo normaal 4 llK bo 110).1Normaal 20 (IK 90-110).3. Inrellektl/e1e Dom-normaal 1 (IK 80-89).vermoells. GrensgevaJ 0 (lK 70-79).Onder-normaal I (lK 60-69).l Onopvoedbaar 1 (IK onder 60).4. Ol/derdom. It jaar - 14 jaar. (Piek, rondom 7 jaar).5. Die eeTprobleme verder ontleed-hoofprobleem.Weiering om te eet 14Vehug IIBraking 26. lnsidensie vall sroornisse wat met die eetprobleem gepaardgegaan het.(i) lnsidensie van funksionele somatiese klagtes.Abdominale pyn 6Moegheid en vae gewrigs- en spierpyne 2AlIergiese manifestasies 1Asemloosheid 1(ii) lnsidensie van versteuring van die pr:mere liggaams-funksies.Enurese 4Enkoprese 2Slaapstoornis 2Spraakstoomis I(iii) lnsidensie van stoornisse I.o.v. gedrag.Aggressiewe gedrag en woedebuie 5(i\') Stoorn;s met betrekking tot die skool.Swak vordering op skool 3Skoolvrees I(v) Psigoncurotiese toestande.Angstoestande 2(vi) Stoornis a.g.v. liggaamlike gebrek of orga-niese siekte 2(vii) Eetstoornis is selds:.am of feitlik onbekend a.g.v. swak-sinnigheid en psigoses in die kinderjare.OPSOMMI 'GDie belang van emosionele en sosio-kulturele faktore as oor-sake van eetstoornisse by kinders word kortliks uiteengesit endie diagnostiese proses word aangedui. Daarna word 'n kortontleding gegee van gevalle met eetstoomisse wat gedurendedie afgelope 4 jaar by die Kinderpsigiatriese Kliniek van diePretoriase AIgemene Hospitaal gesien is.SOME OBSERVATIONS ON THE STATE OF NUTRITION OF INFANTS AND TODDLERSIN SEKHUKHUNILANDP. M. LEARY, M.B., CH.B. (CAPE TOWN), D.A., D.C.H., D.OBST., R.C.O.G.; AND J. E. S. LEWIS, M.A., B.M., B.CH.(OXON), lane Furse Memorial Hospiral, via Middelburg, TransvaalThe figures presented in this paper have been abstractedfrom the records of a weekly infant welfare clinic at theJane Furse Memorial Hospital, a mission hospital situatedin the Bantu Reserve of Sekhukhuniland in the North-Eastern Transvaal.MATERIAL AND METHODSThe children attending the infant welfare clinic are aselect group in so far as only those living within walkingdistance of the hospital, a radius of about 5 miles, are ableto attend. It is primarily a 'well-baby clinic' and anychildren found to require specific medical attention arereferred to the hospital's outpatient department. For thepurpose of this study all regular attenders between July1964 and January 1965 were included, and a study wasmade of weights recorded on the clinic days closest to1 July, 1 September, 1 November 1964 and 1 January1965. Children attending the clinic are weighed at eachattendance and issued with small bottles of Vi-Daylin,Pronutro and dried skimmed milk. In most instances 1 lb.of each was given at every attendance during the periodunder consideration. Those under the age of 6 monthswere given dried skimmed milk if this seemed desirable, asin the case of twins.152 children were studied whose ages ranged between 2and 24 months on 1 July. Of these, 96 attended both at thebeginning and the end of the experimental period andcould be used for a comparative weight-gain study. Inmany cases the exact day of birth was known. In the rest,the month of birth could be determined accurately.Weights recorded at the clinic attendances closest to 1July, 1 September, 1 November and 1 January wereplotted against the age in months of the child on eachoccasion.RESULTSThe mean weights of the children at different ages arerepresented in Fig. 1 by the lowest curve, with the3rd, 10th and 90th Boston percentile' curves shown for'v ]1 12 '3 '4 '3 IS .• 3 19 :: ~l ~~ :! g;.,G: \ :-:0 i-~Fig. 1. Average weights recorded at Jane Furse comparedwith 'Boston' percentiles. Range of weights at each monthof life shown by vertical lines.18 Desember 1965 S.A. TYDSKRIF VIR GENEESKUNDE(Byvoefisel- Suid-Afrikal/llSe Tydskrif vir Voedillg)1157V 91Fig. 2. Weight changes of 96 children in the 6-monthperiod.men live at home, not even seeking work, and providingno income for the family. The illegitimacy rate is high andseveral of the mothers attending the welfare clinic areunmarried. An illegitimate child, according to our defini-tion, is a child born from a casual relationship, in whichthe father makes no contribution to the support of thechild, and may in fact never even see it. We do notinclude under this heading the many cases of stablecohabitation which may arise because the man cannotafford the marriage price. It is also fairly common in thisarea for a man to have more than one wife.The figures obtained in this survey correspond to thoseof other observers in various parts of Africa. The birth-weights of Bapedi infants are lower than those of Whitechildren, but during the first 6 months of life, unless theyare weaned, they gain weight satisfactorily. Thereafter, asthe supply of breast milk becomes inadequate, the rate ofgrowth falls away. It is usual for Pedi infants to be breastfed on demand until they reach the age of about 18months; solid foods are often introduced within a fewdays of birth, and usually by the age of about 4 months.Traditionally Pedi weanlings are given motepa, a gruelprepared from mealie meal and water. According to Quin,'quoting Fox and Goldberg, this contains 0-46 G of crudeprotein per ounce. Questioning at the hospital has elicitedthe fact that many of the weaned children exist on a dietof buswa, or hard porridge only. This contains 0·8 G ofcrude protein per ounce.' Some of the children receivemorogo--a type of wild spinach, which contains approxi-mately 1 G of crude protein and 0·3 mg. of vitamin C perounce. As the survey took place during an unprecedenteddrought, stocks of this were in short supply.The Pronutro and dried skimmed milk issued to thesechildren were intended to act as a complement to tradi-tional foods, and since no child attending the infant clinicregularly developed overt nutritional oedema or kwashior-kor, a small measure of success may be claimed. However,the figures show that, as measured by weight gain, thenutrition of the infants and toddlers who received thesesupplements leaves much to be desired. Although it is usualfor underweight children to gain more weight than normalchildren when given a satisfactory diet, this growth spurtdid not occur among those studied in this survey, showingthat the supplements were far from adequate. It wasimpossible of course to assess how much of the foodissued for a particular child was shared by other mem-bers of the family, but it is felt that this certainly occurred.Although accurate figures are not available, it is unusualto encounter nutritional oedema or other signs of frankmalnutrition in children over 4 years old. Undernutritionis widespread and many of the children are thin andundersized. However. in child~en old enough to fend forthemselves to a certain extent, overt signs of malnutritionare rare. A knowledge of edible herbs and plants has beenacquired and herd boys undoubtedly supplement their dietwith milk direct from the animals they tend. Amongchildren attending schools in this area malnutrition is notseen. Thus the provision of school meals obviously achievesits aim.It is our contention that malnuhtion in· this Reserveneeds to be tackled primarily in the age group 9 monthsto 3 years when morbidity and resultant mortality, usually2 1 0 I 1 ~ ... 5<OHm; •• " 0~~c.~~e g~ ~ 3100<:>:.comparison. The range of weights recorded at each monthof life is shown by the vertical lines.In the first 6 months the curve approximates closely tothe 10th percentile of the Boston figures, but from theage of 7 months there is an increasing discrepancy. Al-though at each month a few children have weights withinthe Boston normal range, the majority fall well beloweven the 3rd Boston percentile. It should be noted thatmany of these children had already been receiving foodsupplements for several months before the survey started,and all received them during the time of survey.In order to demonstrate weights gained during theperiod under consideration, the 96 children with an attend-ance close to both 1 July and I January were divided into4 age groups. There were 24 children between 2 and 6months old on 1 July (group 1), 32 children between 7 and12 months (group 2), 29 between 13 and 18 months (group3) and 11 children between 19 and 24 months (group 4).In Fig. 2 the gain in weight of the 4 groups of childrenduring the 6-month period has been represented by meansof histograms. It will be seen that in group 1 all theinfants gained weight, but there was considerable varia-tion in the amount of weight gained; 5 children gained2 lb. or less. In group 2, three children actually lostweight. In groups 3 and 4 weight gains were less variableand averaged less than in the previous 2 groups. In group1 the average weight gain was 3 lb. 4 oz. in the 6-monthperiod. In group 2 it was 3 lb., and in group 3 it was2 lb. 11 oz. Children in group 4 gained an average of2 lb. 14 oz.DISCUSSION AND RECOMMENDATIONSSekhukhuniland is typical of South Africa's Bantu home-lands in having a widely scattered population living insmall villages, or isolated kraals, linked by rough pathsand bad roads. Medical care for most villages is limitedto a fortnightly visit by a doctor from one of the twomission hospitals serving the area. Figures do not existfor infant and child mortality rates, but from retrospectivequestioning of mothers of children admitted to the hospitalit would seem that at least 50~~ of all children born alivefail to reach their fifth birthday, and the majority of thosewho die do not reach their third birthday.In most cases the men work in towns and spend only afew weeks each year with their families. Although somesend money home regularly, many seldom make any con-tribution to the upkeep of their wives and children. Other115892S.A. MEDICAL JOURNAL(Supplement - Sourh African Journal of urrition)18 December 1965from kwashiorkor or infection, is highest. At the presentstate of development of these people, the weekly distribu-tion of dried milk powder, Pronutro and, in some cases,fortified soup powders is not sufficient. The milk is notalways properly reconstituted, being often far too dilute.Quin' has shown admirably that the traditional Pedi dietcontains sufficient of all essential nutriments. However, thecombined effects of Western civilization and a long andserious drought have modified and depleted the traditionaldiet, and the vast majority of children subsist on a mealie-porridge diet, which makes protein supplements obligatoryif they are to survive.We feel that in a Bantu Reserve such as this, with awidely scattered population, malnutrition can only betackled realistically by the use of mobile soup kitchenswhich visit given areas at least 3 times a week for thedistribution of reconstituted high-protein soup, fortifiedbiscuits such as 'Kokstad' type, and dried skimmed milkwhich the people may reconstitute themselves. Clearly anundertaking of this magnitude is beyond the financialmeans of mission hospitals, and would have to be financedby the State. We contend that the reduction in childmorbidity and mortality, with the saving of hospital ex-penses and the ultimate increase in available labour forindustry, mines, etc., would make this step financiallyworth while. It may be, too, that the lack of energy,mental drive and moral responsibility which characterizeso many Bantu in adult life, could be traced to chronicundernutrition during the important years of growth anddevelopment in early childhood.MORNING SESSION - 13 April - OGGENDSIlTINGChairmanjVoorsitter: Dr. R. E. CronjeSUMMARYA study was made during the period July 1964 to January1965 of the weights of 152 regular attenders at a weeklyInfant Welfare Clinic in the Bantu Reserve of Sekhukhunilandin N.E. Transvaal.A graph plotted of average weights of Pedi infants at eachmonth of life from 2 to 24 months shows that after the ageof 7 months the curve falls well below even the 3rd Bostonpercentile, in spite of the fact that all these children werereceiving regular supplements of dried skimmed milk, Pro-nUtrO and Vi-Daylin-some for several months before thesurvey started. The weight gain of 96 infants over the 6-monthperiod was analysed, and it was found that this averaged 3 lb.4 oz. in the group 0 - 6 months on I July; 3 lb. in the group7 - 12 months; 2 lb. 11 oz. in the group 13 - 18 months, and2 lb. 14 oz. in the group 19 - 24 months. Three infants in thegroup 7 - 12 months actually lost weight.Pedi weanlings usually receive morepa (soft mealie porridge)containing 04 G crude protein per ounce. Many, however,exist solely on a diet of buswa (hard porridge) containing0·8 G of protein per ounce. Although no child receivingregular food supplements at the clinic developed overt nutri-tional oedema or kwashiorkor, the figures obtained showedan appalling degree of undernutrition from which most neverrecover. At least 50% of Pedi infants would seem to die beforetheir fifth birthday.We contend that the productivity of the Bantu in adult lifecould be increased if a large-scale feeding programme forinfants (and their mothers) were instituted, and suggest thatmobile soup kitchens should visit given areas at least 3 timesa week for the distribution of reconstituted high-protein soup,fortified biscuits and dried skimmed milk.REFERENCES1. Nelson, W. (1964): Textbook of Paediatrics, 8th ed., p. 42, fig. 18.Philadelphia: W. B. Saundets.2. Quin, P. J. (1959): Foods and Feeding Habits of t1le Pedi, p. 152.Johannesburg: Witwatersrand University Press.3. ldem (1959): Ibid., p. 143.4. ldem (1964): S. Aft. Med. J., 38, 969.CAN WE ERADICATE MALNUTRITION IN SOUTH AFRICA?M. L. NESER, National Nutrition Research Institute, Council for Scientific and Industrial Research, PretoriaIf the question asked in the title of this paper is viewedfrom a philosophical angle, the answer must obviously be'no'. We do not yet know enough about nutrition, andprobably never will know enough, to be able to say withcertainty exactly what amount and variety of food is bestsuited to the needs of any particular individual. If we hadthis knowledge we would have no way of imparting it,except through individual counseIling-a method whichobviously cannot be applied to whole populations. Buteven if we had the necessary knowledge and the means ofimparting it, and even if everybody had unlimited accessto ali the foods we might prescribe, we should still haveno means of ensuring that our advice was followed. Aslong as human beings are free to eat what they like therewill be those whose appetites will lead them astray, whowili eat too much or too little, or those who will deprivethemselves of one type of nutrient in order to overindulgein another. The human appetite, even in young children,is a most unreliable guide to the body's needs, for it canall too easily be influenced and perverted by factors quiteunrelated to actual nutritional requirements; and it mustbe acknowledged that next to food availability appetite isthe major controlling factor in human food consumption.In comparison with the compulsive influence of appetitethe influence of common sense and nutrition education isoften very weak indeed. Even the knowledge that suddendeath may result from unrestrained eating is often insuffi-cient to induce a human being to change his eating habits.With these factors in mind it can be seen that there isno prospect whatsoever of completely eradicating malnu-trition in South Africa or anywhere else, for many of thefactors which lead to malnutrition are inherent in ourhuman condition. However, although there is probably agreat deal of malnutrition in this country that is notamenable to correction, there is undoubtedly a very highincidence of malnutrition owing to factors that can, intheory at any rate, be corrected or eradicated. It is thispreventable malnutrition as it occurs in the country as awhole and the prospects of its eradication that I wish inparticular to consider in tills paper.Before proceeding with a consideration of the factorsinvolved in the malnutrition problem, I should like to de-

Some observations on the state of nutrition of infants and toddlers in Sekhukhuniland

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Some observations on the state of nutrition of infants and toddlers in Sekhukhuniland

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