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What Is Malnutrition?

Hundreds of thousands of American
children are undernourished

By
LYDIA ROBERTS

litfren's Year Follow-up Series No. 1 Bureau Publication No. 59

U. S. Department of Labor

Children's Bureau

WHAT IS MALNUTRITION?

Malnutrition in children has at last begun to receive the attention,
it deserves. Articles concerning it are appearing in medical jour-
nals, popular magazines, and newspapers; and a variety of agencies
are being set at work to combat it.

It is important that information on this subject should reach par-
ents, teachers, social workers, and all others responsible for the wel-
fare of children. In order to insure this, it has seemed worth while
to summarize in bulletin form the most important facts concerning
the nature, extent^ causes, effects, and treatment of this condition.

SIGNS AND SYMPTOMS OF MALNUTRITION.

The first question which naturally arises is: What^Js^jria 1 mi tr\ -
tion? Is it an infectious disease like measles or whooping cough
which runs its course and then is over? Unfortunately not, other-
wise steps would long ago have been taken to control it. Neither is
it a disease like gout or rheumatism which causes sufficient pain to
demand attention and treatment. It is, in fact, not a disease at all,
but, as Dr. George Newman, chief medical officer of the board of
education (England and Wales), * well expresses it, "a low con-
dition of health and body substance. It is measurable not only by
height, weight, and robustness, but by many other signs and symp^
t6ms." A description of these u signs and aymploins " found in the
undernourished child will furnish a better idea of the meaning of the
term than can any attempt at formal definition. The picture will be
even clearer if its opposite a healthy, well-nourished child be first
described.

A well-nourished child, first of all, measures up to racial and fam-
ily standards of his age in height and weight. He has good color,
bright eyes no blue or dark circles underneath them and smooth,
glossy hair. His carriage is good, his step elastic, his flesh firm, and
his muscles well-developed. In disposition he is usually happy and
good-natured ; he is brim full of life and animal spirits and is con-
stantly active both physically and mentally. His sleep is sound, his
appetite and digestion good, his bowels regular. He is, in short, what
nat ure meant him to be before anything else a happy, healthy young
animal.

A malnourished child lacks several or all of these characteristics of
a normal child, depending on the degree of undernutrition. He is

1 The circlnJ figures used throughout refer to corresponding figures in the list of refer-
ences found on pp. 19 to 20.

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usually tlii) i, I nit HIM be fat and flabby instead. His skin may have
a pale, delicate, waxlike look, or be sallow, muddy, even pasty or
" earthy " in appearance. There are usually dark hollows or blue
circles underneath his eyes, and the mucous membrane inside his
eyelids and in his mouth is often pale and colorless. His hair may
be rough like that often seen in poorly cared for farm animals
his tongue coated, and his bowels constipated. His skin seems loose,
his flesh is flabby, and his muscles are undeveloped. Because of the
lack of a muscular tone, his shoulders are usually rounded, sometimes
protruding to such an extent as to make the deformity known as
" wings " ; his chest is flat and narrow. Decayed teeth, adenoids, en-
larged or diseased tonsils may also be present.

The animal spirits natural to all healthy young are apt to be lack-
ing in the undernourished child. He may be listless in play and
work, will probably tire easily, not care to romp and play like other
children, and will often be regarded as lazy. There is likely to be a
lack of mental vigor also. Little power of concentration and atten-
tion, and absence of a child's natural inquisitiveness and mental alert-
ness are his common characteristics. The expression of his eyes and
of the entire face is often lifeless and dull. In disposition, he may
be extremely irritable and difficult to manage, and he is often abnor-
mally afraid of strangers. He may be nervous, restless, fidgety, and
will probably sleep lightly and be " finicky " about his food.

Such, then, are some of the " signs and symptoms " which may dis-
tinguish a malnourished child from a well-nourished one. It is easy
to see that malnutrition is a relative term. There are all degrees of
undernutrition from severe cases exhibiting practically every symp-
tom described above, to the ones which, though they seem to lack
definite symptoms, still give the general impression of not being just
normal. In actual practice, however, children are called malnour-
ished only when one or more of the various symptoms have become
quite marked, particularly underweight for height and flabbiness of
flesh and muscles. Since underweight is an almost certain result of
faulty nutrition, it has become the custom of many physicians to class
children as malnourished by this one symptom alone. Dr. Emerson,
who was one of the first to direct our attention to the treatment of
undernourished children, has called any child malnourished who is
habitually 10 per cent underweight for height. In a very recent
study he is using 7 per cent as the standard. Dr. Holt considers
10 per cent underweight for height from 6 to 10 years and 12 per
cent from 11 to 16 years indications of undernutrition. He
believes the annual rate of increase in weight and height, however,
to be even more important. Any child, therefore, who is
markedly underweight for his height or who does not gain at the
normal rate can be safely put into the malnourished group. Other

defects will usually confirm the decision. Dr. Emerson finds an
avrnige of five physical defects in a malnourished child to one in a
swell-nourished one.

There can be no question that children 10 per cent below normal
weight for their height should be classed as malnourished, for, as
Dr. Emerson says, " Children do not become underweight to this de-
gree except for adequate causes." (D The only question is, Should
we stop there? In New York City, at least, there are 60 to 70 chil-
dren out of every hundred as figures given later will show who are
not underweight to the extent of 10 per cent, but who are, neverthe-
less, below par in one or more respects. Inquiry into the living
habits of these children almost always reveals a faulty diet or other-
wise defective health program. That they are not underweight may
be due to good feeding during infancy or unusually resistant bodies ;
for it often takes considerable time before the results of bad living
show themselves in loss of weight, anemia, and other definite symp-
toms. It would be worse than folly, surely, to wait for a loss of
weight to tell us that such children are being undernourished.
Would it not be wise, in fact, to regard them as malnourished in
a less degree and consider them safe only when they are known to be
on a suitable diet and living a normal child's life? These are the ones
whom a little influence for good or bad would easily push up into the
excellent group or down into the malnourished one. Now is the
time to see that they get pushed in the right direction. Is it too
high a standard to say that we aim to put all children in the ex-
cellent group ?

EXTENT OF MALNUTRITION.

Knowing the character of malnutrition, the question immediately
follows : What is the extent of this condition ? Are there any consid-
erable numbers of malnourished children in our own and other
countries? And is their number decreasing or increasing?

In France, Belgium, and other countries of the war zone the ques-
tion can have but one answer. In spite of stupendous efforts to pro-
tect the young the shortage of food and other conditions of war have
had disastrous effects on the health of the children. No statistics are
needed to show that the number of undernourished children in these
countries is appallingly large.

In England the condition is less serious, though grave enough to
demand attention. Dr. Newman in his 1915 and 1917 reports
concludes that fully 10 per cent of the school children are
malnourished. So large a number is a matter of grave con-
cern. Compared with the numbers for previous years, however, the
figures show that in spite of the war, the number of seriously under-

nourished children has actually decreased. On the other hand, the
number of children in the best nutritive condition as opposed to fail-
has also diminished. Medical officers attribute the decrease of
marked malnutrition to the higher wages which have made the pur-
chase of an adequate diet possible. The decrease in good
nutrition they believe is explained by the anxiety of mothers to fall
in with the voluntary rationing of the food controller. Speaking
generally, however, the consensus of opinion among English medical
officers is that the children of their schools are, on the whole, in a
better-nourished condition than they were before the war.

In our own country the figures are not so gratifying. We
have no method of obtaining data for the whole country as has
England, so results of certain typical investigations are our only
guides. One of the most recent investigations @ was made in
March, 1918, by the bureau of child hygiene of New York City. Of
171,661 school children from the borough of Manhattan who were
examined, the following results were obtained: Grade I (excellent),
17.3 per cent; Grade II (passable), 61.1 per cent; Grade III (poor),
18.5 per cent; Grade IV (very poor), 3.1 per cent.

A number of scales for grading physical examinations of children have been
devised and used. The Dunfermline scale, (12) @ originated by Dr. Mc-
Kenzie, of Dunfermline, Scotland, was adopted by the bureau of child hygiene
of New York City a few years back and is the one now used generally through-
out the country. This scale divides children into four classes:

I. Excellent. The state of nutrition of a child of superior healthy condition.
(The perfect, well-nourished child described above.)

II. Passable. Children falling just short of excellent. (Sometimes called
fair, or good, or normal.)

III. Poor. Children requiring supervision.

IV. Very poor. Children requiring medical attention.

The ones falling into Classes III and IV are usually considered as cases of
malnutrition.

The value of this scale lies in the fact that it makes grading easy, because
in Groups III and IV it names something definite to be done to a child, and in
Group I it explicitly states that a child so graded is not merely excellent com-
pared with others of a group, but is one who would be considered excellent
anywhere. In making the classification, other factors than weight are, of
course, considered. The general appearance of the child, the condition of the
skin and subcutaneous tissue, the muscular tone and development, the state of
the mucous membrane, the vigor or listlessness which may appear in the
child's facial expression, carriage, movements, voice, interest, and attention,
all contribute to the decision.

Even with such a grading system, however, in which the classes are fairly
well defined, it could not be expected that any two examiners would necessarily
classify a given group of children exactly the same. So long as the work is
done by human beings, the personal equation will enter in. And yet in a test
application of this scale in New York City it was found that physicians agree
on the state of nutrition as well as, or better than, they do on even such common
defects as tonsils and bad teeth. The use of the scale has been criticized,

however, and it must be admitted that the grades are apt to signify very
different things, depending on the examiner. It was found in New York City,
for instance, that physicians in certain sections had become so accustomed to
malnutrition that they had come to regard it as a racial or local tyi<>,
iiud si nco they found no children belonging in Group I they hud used the
scale merely to show degrees of malnutrition. The fact that such grading may
occur hardly seems sufficient ground for abolishing the scale entirely, for it
n>n a inly serves a purpose. It would instead seem wiser to make sure that
all examining physicians are actually familiar with the physically superior
tyi>e: that they know the scale, the requirements for the different grades,
ami understand fully that the standards are to be applied as absolute not
relative ones. Other classifications are sometimes used, as good, fair, poor,
or a five-grade scale of excellent, good, fair, poor, and very poor. It matters
little what scale is used, however, if the standards for each grade are well de-
fined and these standards strictly adhered to in the grading. The advisability
of grading all children instead of disregarding all but the markedly under-
weight ones is evident.

The bureau of child hygiene believed that these figures could be
safely assumed as applicable to the city as a whole. This being so,
New York's 1,000,000 school children would be distributed about as
follows: Normal as regards nutrition, 173,000; passable, 611,000; seri-
ously undernourished, 216,000. According to Dr. Josephine Baker,
@ this last number is a decided increase over those for previous
years. She gives the proportion of malnourished school children
as 5 per cent in 1914, 6 per cent in 1915, 12 per cent in 1916,
and 21 per cent in 1917. With such conditions revealed with over
200,000 malnourished children in their schools, and with the number
rapidly increasing is it any wonder that New York physicians
and child welfare agencies have become aroused to the fact that it
behooves them to do something about it?

These figures are for New York City. To what extent they are
applicable to the country at large we can only surmise; but we can
safely conclude that the estimate so frequently made that 10 per
cent of the children in our country are suffering from malnutrition
is far too low. The estimate given by Dr. Wood that between
15 and 25 per cent of our school children (3,000,000 to 5,000,000) are
undernourished is probably much nearer the truth.

CAUSES OF MALNUTRITION.

The most important question to consider in regard to malnutrition
is, What causes it? Why are so few children in the excellent group?
Why are so many distinctly malnourished and a still larger number
much below par? Are a certain few "predestined" to be physically
fit and others doomed by inheritance to be inferior to a greater or
less degree?

It is easy to blame heredity, and there can be no question that poor
inheritance may handicap a child's development. Physicians are

generally agreed, however, that it is, after all, responsible for but a
very minor part of malnutrition. The majority of children are born
healthy. Given this start, with proper surroundings and nur-
ture, they should develop normally into healthy, well-nourished
children. That this happens in so few cases is definite proof that
there is something wrong with the health program, resulting in faulty
health habits. Failure to provide a child with any one or more
of the necessary conditions for normal growth may result in malnu-
trition. The most important causes of this condition may, therefore,
be readily given.

SPECIFIC CAUSES.

Diet. Insufficient or unsuitable food and drink, such as tea and
coffee instead of milk, is generally conceded to be the chief cause of
undernutrition. The first requirement of a growing child is food.
Every movement his body makes, every bit of work it does, requires
energy, and this energy must be furnished by the food he eats. If
the food supply is insufficient, the body itself is burned to provide
the energy, and loss of weight results. It is essential, therefore,
that the diet of a growing child should be, first of all, generous in
amount. An insufficient and inadequate breakfast of bread and
coffee, whether or not the midday meal is adequate, practically always
means too little total food, even though a hearty supper may be eaten.
Indulgence in sweets and highly seasoned foods, habitual eating be-
tween meals, late hours, unventilated sleeping rooms, and lack of
exercise may all result in a " finicky " appetite and thus in the taking
of too little food. Whenever the food eaten habitually falls below
the actual need, no matter for what reason, malnutrition is the un-
failing consequence.

A diet inadequate in the kind of food has equally disastrous re-
sults. To be well nourished, a child must have every day some body-
building material, or protein, to help form his -muscles, his blood, his
heart, his lungs, his brain, and all other living parts of the body.
Without it his muscles can not develop normally nor his organs be in
the best condition. Certain proteins of animal origin those of milk,
eggs, and meat are more valuable for growth than are those of
cereals, beans, peas, and vegetables. A liberal amount of the child's
"building material," therefore, should be furnished by foods of
animal origin. Failure to supply these in sufficient amounts may
result in undernourishment.

Another specific need of the child's body is for minerals. He must
have plenty of lime to build sound bones and teeth, iron to make red
blood, and other minerals for just as definite uses. Without suitable
amounts of lime and phosphorus, his bones will surely be spongy
and his teeth defective, while a lack of iron causes anemia. In this

condition the blood has not enough normal red corpuscles to carry
sufficient oxygen to the tissues to burn the food, and loss of weight
follows. Since milk is about the only liberal source of lime, and
since vegetables, fruits, whole cereals, and egg yolks, in addition to
milk, supply most of the other minerals, it is readily seen that many
cases of malnutrition are caused by too little of one or more of these
foods.

In addition to proteins and minerals, a child's diet must contain
some of the growth-regulating substances commonly known as " vita-
mines." One, called water soluble B by Dr. McCollum, is found
abundantly in vegetables, fruits, milk, and all natural foodstuffs.
Another (fat soluble A) is less widely distributed. It is found
in liberal amounts in the fat of milk, egg yolks, and glandular organs,
and in the leaves of plants. There is little danger that an ordinary
diet, unless made up of too purified foodstuffs, will be lacking in the
first ; but it is quite possible that many children who have no leafy
vegetables and practically no milk or eggs may fail to grow nor-
mally because of an insufficient amount of the fat soluble vitamine.
Without fairly liberal amounts of milk, leafy vegetables, and eggs,
therefore, the diet can hardly fail to be lacking in minerals, growth
proteins, and the necessary vitamines. Malnutrition of many chil-
dren may be laid to the fact that they receive too little of one or more
of these necessary foods.

Indigestible foods and faulty habits of eating may also help to
cause undernutrition. We have unquestionably gone a long way
when we have provided a diet for a child which is ample in amount
and adequate in quality. In ideal feeding, however, the suitability
of the food, the hours of eating, and all other food habits must be
considered also. It must be remembered that the child's digestive
tract is far from being fully developed and should not, therefore, be
expected to take care of all foods suitable for adult use any more
than an immature body can be expected to do the work of a man. It
is important to all his future life that his organs be not overtaxed
nor his digestive system weakened while he is young. To insure this
demands the provision of simple, well-cooked, easily digested foods ;
the exclusion of all rich, highly seasoned, indigestible ones; the intro-
duction of new foods only gradually ; and regular, unhurried meals,
with no indiscriminate eating between meals. Failure to take account
of these factors may cause indigestion and weakened powers of diges-
tion and assimilation. If the body is unable to use the food pro-
vided, malnutrition is as certain as if the diet were inadequate in
amount. (For further material on children's food, see Child Care,
pages 11-30; Milk, the Indispensable Food for Children; and Feed-
ing the Child, Dodger No. 8, published by the Children's Bureau.)

Sleep. Insufficient sleep and other faulty health habits are also
responsible for malnutrition. Experiments with undernourished
children have shown that even after the diet has been regulated
122217 19 2

children do not gain properly unless the hours of sleep are also
sufficient and regular. Teachers and others dealing with large
groups of children testify to the fact that children of early age AYJIO
should be in bed not later than 7 or 8 o'clock are retiring at 9, 10,
11, or even later. The sleep problem surely needs attacking as well
as the 'food problem.

Fatigue. The importance of rest, both mental and physical, as
part of the treatment of undernourishment is plainly demonstrated
by classroom work in the schools. Certain children will not gain
until removed from school or allowed only a half-day session. Rest
periods of one-half to one hour are found necessary to guard against
overfatigue in these chidren. Complete physical relaxation by lying
down on the back for even 15 minutes will give better results than a
longer time of partial rest. These rest periods should be taken pref-
erably before the midmorning lunch and the evening meal, and are
most effective when combined with the open window.

In addition to too little sleep and fatigue, lack of fresh outdoor
air and exercise, constipation, unhealthful living conditions, and
undue excitement may also be contributing factors to malnutrition.

Defect and disease. Enlarged and diseased tonsils, adenoids, de-
cayed teeth, tuberculosis, and syphilis are also causes of under-
nutrition. Adenoids and enlarged tonsils may act in two ways.
They obstruct the free passage of air to the lungs, thus limiting the
oxidation of food in the tissues, just as closing the draft to a stove
keeps the fire from burning. Then, too, these abnormal growths are
apt to become diseased, when either their toxins may circulate
through the body and prevent the building up of tissue or even
destroy it, or secondary seats of focal infection may arise from germs
from these diseased areas being carried by the blood to distant parts
of the body. It is not strange, therefore, that severe cases of mal-
nutrition are sometimes cured by merely removing these growths.

Bad teeth, of course, may be the result of undernutrition, but they
may in turn help to cause it. They may become sources of infection
similar to tonsils and adenoids and thus in the same way cause tissue
destruction.

Probably the most active agent in tearing down the body, once it
attacks it, is tuberculosis. It not only gradually destroys the organ
which is infected, but its toxins, like the ones already mentioned,
are so pernicious that only the strongest, most robust body can with-
stand them. It will be seen later that all these factors diseased
tonsils, adenoids, decayed teeth, and tuberculosis may be .results
as well as causes of malnutrition. When these physical defects are
present they become even more important than food or sleep in caus-
ing undernutrition. No matter how much wholesome food a child
eats, if he has not enough oxygen to burn it, or if the body is being
torn down as fast as it can be built up, there is little chance for him
even to hold his own, much less to gain.

Children who are victims of congenital syphilis usually exhibit
marked malnutrition. The nutrition problem, in fact, may appear as
the most serious feature in such cases and persist unhelped until
specific medication is used.

UNDERLYING CAUSES.

Poverty. Before we attempt to correct malnutrition, however, it
is necessary to go still further back and inquire into the underlying
causes of the specific ones. Why are children insufficiently fed?
Why do they have too little sleep? Why are bad teeth and tonsils
not attended to? The answer seems to be that poverty, ignorance,
and lack of parental control, singly or together, are the responsible
factors. Not long ago it was customary to lay practically all the
blame on poverty. Recently,' however, there is a tendency because
of the discovery of the importance of the other two factors to dis-
regard it somewhat as a cause, of malnutrition. Either extreme, of
course, is wrong. An intelligent woman can undoubtedly come much
nearer providing an adequate diet for her family on a limited in-
come than can an ignorant woman with the same money she may
even succeed where the other fails but the fact remains that there
is a certain minimum income below which not all the intelligence in
the world can purchase an adequate diet. It must be remembered,
too, that it is poverty in a host of cases which is the real cause of
ignorance. Had these poorer people the means, would they not in
fact move into a better part of town, live in better houses, and pur-
chase a better diet merely because of the natural desire for more and
varied foods? And would they not naturally come into contact with
influences which would to a certain extent educate them ? Indeed, if
we desire proof that this is so, we need but recall the fact that in
England, even in the midst of war, with mothers away from home
working and .the children more or less neglected, the per cent of
markedly malnourished children decreased rather than increased, as
it was feared and expected would be the case. This decrease, as be-
fore mentioned, is attributed by English authorities to the high wages
which made it possible for families to have better and more abundant
food and more desirable living conditions.

Although we have come to know that poverty is not the only
underlying cause of malnutrition, we must not forget after all that
the first big step toward removing large 'numbers of children from
the ranks of the undernourished would be to insure their parents an
income considerably above the mere subsistence level.

Ignorance and lack of parental control. Abundant proofs that
ignorance and lack of parental control are in many cases even more
important factors than poverty are not wanting. Studies of home
conditions have shown that children are insufficiently fed because

parents are ignorant of what are proper foods, of how to spend
their money to get the best return in food value, of the necessity of
regular, unhurried meals, of the need of a good breakfast for a grow-
ing child, of the harmfulness of tea and coffee and the habit of
eating candy and trash between meals. Ignorance, as well as poverty,
is to blame for much of the unhygienic living; and the same can be
said of lack of attention given to teeth and to physical defects. Re-
moval of this parental ignorance without any change in the financial
condition whatever will, in a host of cases, be sufficient to effect the de-
sired improvement in the child's nutrition.

Even when poverty is not a factor and when ignorance does not
exist or has been removed, there still remain many children who are
undernourished merely for the lack of wise parental control. Even
when they know better, a large number, of parents allow their chil-
dren to eat what and when they like, to live under continual stimula-
tion and excitement, and to choose their own time for going to bed.
Truly it has become in this respect to far too great an extent the
" age of the child."

EFFECTS OF MALNUTRITION.

Why 'worry about malnourished children ? Many of them manage
to keep alive, to pass through school, and grow up to take their
places in the world as men and women. Does it make any difference,
then, if they are undernourished now ? It does, indeed, make a great
difference. "Malnutrition," says the chief medical officer of
England after many years of observation of its effects, " is one of tho
gravest evils of its [the child's] physique. The malnourished child
tends to become disabled, and unemployable, incapable of resisting
disease or withstanding its onset and process." Its evil effects, as
we shall see, are shown both in the physical and mental development
of the child.

PHYSICAL EFFECTS.

Stunted growth, anemia, nervousness, irritability, and diminished
energy have already been shown to be accompaniments of malnutri-
tion. From the standpoint of comfortable living alone, these are
important. A nervous, restless, irritable child or adult is a constant
drain on the life of all his associates, and a lifeless, uninterested one
is no joy to himself nor to anyone else.

The results of diminished energy, however, are even more far-
reaching. The listless, inactive, malnourished child who is con-
stantly tired, who leans against the schoolhouse while his comrades
play, is father to the man who is handicapped because of low vitality
and a poorly developed body, and hence unable to do his full share
of the world's work. He is the inefficient adult, the rejected army

recruit. A proof of this was shown at the time of the Boer War,
when England was shocked to learn that three out of every five men
who applied for service were physically unfit. The commission ap-
pointed to inquire into the reason returned the verdict that malnu-
trition of children was one of the most serious causes. In our own
country at the beginning of the recent war practically the same situa-
tion was repeated. Startlingly large numbers of applicants had to
be rejected because of physical unfitness, and again the consensus
of opinion blamed malnutrition and remediable defects of infancy
and early childhood.

One of the most serious results of malnutrition is shown in in-
creased susceptibility and lack of resistance to disease. Let an infec-
tious disease, such as measles, whooping cough, or scarlet fever, attack
a neighborhood and the difference between the well-nourished and
the malnourished child at once appears. The child in fine physical
condition may not escape the disease ; but if he does contract it, he has
more vigor to withstand the attack and his recovery is usually rapid.
The undernourished child, on the other hand, especially if he has
bad teeth, diseased tonsils, or adenoids, usually "takes" the disease,
probably has a more serious, case, and recovers with greater difficulty,
if at all. A large proportion of mortality among children is due
directly or indirectly to faulty nutrition. Scarlet fever, diphtheria,
measles, pneumonia, tuberculosis, and intestinal diseases claim
most of their victims from those who have not sufficient stamina to
resist them.

The relation between malnutrition and tuberculosis needs special
emphasis. We have seen that tuberculosis may be an active cause of
malnutrition, and we now find that a malnourished body is the best
soil for tuberculosis. It is a vicious circle. Malnutrition makes the
child susceptible to tuberculosis, which, once started, tears down the
body and increases the degree of undernutrition. This in turn makes
the progress of the disease still easier, and thus the process continues
until the end. The only possible way to withstand tuberculosis, once
infection has occurred, is to build up so fine and well-nourished a
body that the disease can make no headway.

If mothers could be taught to regard undernutrition as an abnormal
condition, likely to result at any time in serious illness and possible
death, they could be more easily persuaded to strain every effort to
bring their children up to normal, and they would cease to take pride,
as do many mothers even yet, in having a " delicate " child.

MENTAL EFFECTS.

The effect of nutrition on mental development has long been recog-
nized. There has, indeed, been shown to be a close relation between
malnutrition and backwardness in school. Experiments in school
feeding, both here and abroad, have shown that an improvement in
the nutrition of a child is in practically all cases accompanied by

mental improvement also. Teachers testify that the children are
easier to teach, have greater power of concentration and attention,
and are able to do better work, as is shown by their school grades.
This is not difficult to understand, for a starved brain can not be
expected to work efficiently any more than can a starved body. It
is not surprising, therefore, to find considerable retardation in mal-
nourished children.

Dr. Tredgold, one of the leading authorities on mental defi-
ciency, tells us that in some cases this retardation due to malnutrition
may be so extreme as to make it almost impossible to distinguish it
from actual mental defect. That it is not so is shown by the rapidity
with which the child becomes mentally normal when the adverse
factors causing the subnormal physical condition are removed. Dr.
Tredgold believes it possible, however, for malnutrition to be so
severe and prolonged that a degree of actual mental deficiency of
secondary form may be produced. Such cases he admits are very
uncommon, but, since he has had a number of cases in which no other
cause could be assigned, he holds to the opinion that they may occur.

It is thus seen to be imperative from the standpoint of the mental
as well as the physical welfare of the race that every means should
be used to make and keep the rising generation physically sound and
well nourished.

TREATMENT OF MALNUTRITION.

The first step in the treatment of malnutrition is to find the cause.
This means a careful inquiry into the child's whole method of living,
as well as a thorough standardized physical examination. () The
cause discovered, the next step, obviously, is to remove it. Some-
times this is a comparatively simple matter, and again the child's
whole program of life needs to be thoroughly overhauled. Tonsils
and adenoids may need to be taken out, bad teeth cared for, the diet
regulated, and a new scheme of living instituted. If poverty is a
determining factor, the help of relief agencies must be enlisted;
ignorance of the requirements of adequate food and healthful living
must be replaced by knowledge; and parents urged to exercise a
wiser, firmer control of their children's way of living. To do all
these requires a program of health education and sometimes even the
provision of opportunities for securing proper food and living in the
fresh air. Some of the agencies which have been established to meet
these needs are discussed in the following sections.

SCHOOL LUNCHES. @

School lunches were established in England almost immediately
following the discovery in 1900 of the extent of malnutrition in that
country (discussed on p. 13), and have been extensively used there.
During the year 1914r-15, a maximum number of 29,560,316 meals

were served by the educational authorities. <) These lunches are
of the extra meal type, sometimes being a breakfast, sometimes a mid-
morning lunch, and again only a cup of milk. They minister largely,
though not entirely, to the children of the poor, and their use is based
on the belief that insufficient food is the chief cause of poor nutrition.
The results of school feeding in England have been so beneficial to
the children in every way that the school lunch as a specific measure
for dealing with malnutrition has become a firmh 7 established in-
stitution.

The American school lunch is of two types. One, like the Eng-
lish, is the midmorning lunch, meant to supplement the scanty break-
fasts which so large a number of children have, and to provide extra
nourishment which often seems to be necessary in order to cause
underweight children to make proper gains. New York, Phila-
delphia, Chicago, and other cities have started lunches of this kind,
but even in these cities only a beginning has been made. The chil-
dren pay for their lunches for the most part, but provision is also
made for those who are unable to do so.

The other type is the hot midday lunch which is provided for chil-
dren whose mothers are away from home, who live too far from
school, or who for other reasons are unable to go home at noon.
These lunches are being widely introduced thoughout the country.
''Special impetus has been given, the last few years, to the movement
of supplying a hot noon meal for children of the rural schools also.

It can not be doubted that both types of lunch have been factors
in improving the condition of children. It is true, however, that the
school lunch has never done as much as it could and should do. Chil-
dren, for the most part, choose their food unsupervised and thus too
often have lunches inadequate in amount and unsuitable in kind, in
spite of the fact that the school provides them. There is need that
the school lunch should be recognized and used as one of the school's
greatest opportunities for health instruction. Dr. Emerson has de-
cided from his experience that a malnourished child can use food
given in five small meals much better than if the same amount of food
is given in three meals.

FRESH-AIR CLASSES OR SCHOOLS.

In the United States open-air rooms and schools have been em-
ployed for a number of years for tuberculous children, but of recent
years they are being used for malnourished children to some extent.
With nourishing food, fresh air, and physical and mental work
suited to their condition, it is needless to say that the gain of these
children in all respects is usually striking.

Dr. Newman in 1917 expressed regrot that provision for edu-
cation under these open-air conditions had not increased more rapidly.

He urged strongly what could be equally well recommended for the
United States that more of these schools be established for the mal-
nourished children of Great Britain.

NUTRITION CLINICS AND CLASSES.

One of the most effective methods of dealing with undernutrition
is the malnutrition clinic, or, as it is better called, the nutrition class.
Dr. Emerson () as long ago as 1910 was conducting such a class in
Boston, and more recently others () <g) <) @ @ have been
started in New York City, while scattering ones are reported in a
few other cities. () Briefly, the conduct of a malnutrition class is
as follows: ()

Groups of underweight children meet weekly to be weighed, are
examined by a physician, and given class instruction in food values
and hygiene. Weight charts are kept (see p. IT), and the children
compete to see which can gain most or be first to reach the normal
weight lines. Any physical defects, such as diseased tonsils and ade-
noids, are always cared for first, as no gain can be expected until
these causes are removed. Visits to the home to study home condi-
tions and to engage the interest of the parents in carrying out the
classroom instruction are a necessary and valuable part of the work.
Mothers are urged to come to the class, but the instruction is given
primarily to the children. The cooperation of the child is, in fact,
the biggest factor in the success of the class. Once a boy becomes
interested in his weight curve, he will drink milk, eat vegetables and
oatmeal, go to bed earlier, open his windows, and take the necessary
rest periods things his parents may have been almost powerless to
get him to do. The repeated health instructions, together with the
weekly checking up and the spirit of class competition, combine to
produce, on the whole, excellent results. Many of the children make
almost startling gains and most of them gain at more than the ex-
pected rate.

There is general agreement that this type of work should be ex-
tended. Classes need not be confined to the dispensaries where they
started, but may be conducted in schools, settlement houses, day
nurseries any place where children are gathered together. The
school is the logical place for this health instruction. Here regu-
larity of attendance can be easily secured; and the combined efforts
of the medical service, hygiene classes, the physical training exer-
cises, the domestic science department, and the school lunch, as well
as the general school activities, can all be utilized to insure that all
the children learn and, during the school day at least, practice health-
ful, hygienic living. Chicago has just started a city-wide campaign
of this ^nature in its public schools. The field has been surveyed,
scales for every building have been purchased, and the work is
already begun in a few schools. It is to be hoped that this movement
will soon be nation wide.

SPECIMEN CHART KEPT FOR EACH CHILD UNDER TREATMENT BY

THE CLASS METHOD. 1

ROBERT M

Red star, represented by^, means daily lunch; blue star, represented by
0, means daily rest period; gold star, represented by f, means greatest
gain in week. The weight curve is that of a child chosen because he was
under constant observation day and J&ht, together with 11 other children, all
of whom lost weight on these same dates when lunches and rest periods were
omitted the week preceding. On the original chart the weight curve is in
red. Diagnosis of the cause of gain or loss in weight of children in the school
could be made by inference only, and therefore could not be verified.

1 Prepared by Dr. Wm. R. P. Emerson and published in an article by him on " A nutri-
tion clinic in a public school," in the American Journal of Diseases of Children, vol. 17
(April, 1919), p. 260.

18
CHILDREN'S YEAR CAMPAIGN.

The agencies already referred to have been concerned only with
the child of school age. It is during the preschool period, however,
that malnutrition usually starts. The Children's Bureau by this
past year's campaign for children of preschool age has at last cen-
tered the attention of the country upon this "the neglected age."
The program for Children's Year which the bureau outlined has
been carried out by the local child welfare committees organized under
the Child Conservation Section of the Council of National Defense.
Through, weighing and measuring tests and conferences on child
welfare, an enormous number of children has been reached. Greater
even than this work, however, will be that which States, cities,
social organizations, physicians, and parents have been roused to do.
Some cities have instituted a house-to-house canvass to examine chil-
dren for malnutrition, diseased tonsils, adenoids, and other defects,
and a movement to extend the work of infant-welfare centers to
children of this group has already begun.

Adequate prenatal care is becoming more and more general ; babies
up to 2 years of age are for the most part looked after either by
private physicians or infant- welfare societies. When all infant-wel-
fare agencies assume responsibility for the preschool child ; when all
schools, through proper medical attention, health instruction, school
lunches, and healthful schoolroom conditions, insure suitable ca*re
of the school child ; then the ideal continuous health supervision of
children from conception through all the growing period will come
near to being realized. Then, and not till then, can we hope to solve
the problem of the undernourished child.

REFERENCES.

Newman, George, M. D. : Annual Report of the Chief Medical Officer,

Board of Education (England and Wales), 1915-16, p. 32.
Ibid., 1912-13, p. 26.
Emerson. Wra. R. P., M. D. : " Foad habits of delicate children," in New

York Medical Journal, vol. 105, 1917, p. 361.
- - "A nutrition clinic in a public school," in American Journal of

Diseases of Children, vol. 17, 1919, p. 251.
Holt, L. Emmett, M. D. : Discussion : " Standards for growth and nutrition

of school child," in Archives of Pediatrics, vol. 35, 19.^8, p. 3.",!).
- - "Standards for growth and nutrition," in American Journal of

Diseases of Children, vol. 16, 1918, p. 359.
Newman, George, M. D. : Annual Report of the Chief Medical Officer,

Board of Education (England and Wales), 1917-18, p. 126.
Ibid., 1915-10, p. 142.
Ibid., 1917-18, p. 8.

@ Chapin, Henry D., M. D. : " The national danger from defective develop-
i*- of growing children in time of war," in Medical Record, vol. 93,

89.
@ ; attrition among school children," in Weekly Bulletin of the Depart-

r of Health, City of New York, vol. 7, March 9, 191S. p. 75.
y, Frank A. : "A scale for marking malnutrition," in School and
Society, vol. 3, 1916, p. 123.

- "A comparison of three methods of determining defective nutri-
Jtion," in Archives of Pediatrics, vol. 35, 1918, p. 88.

Baker, S. Josephine, M. D. : " The relation of war to the nourishment of
children," in New York Medical Journal, vol. 107, 1918, p. 289.
Wood, Thomas D., M. D. : War's Emphasis on Health Education (address
3 before the National Council of Education, February 28, 1918, published

in the New York Times, April 14, 1918).

McCollum, E. V. : "The supplementary dietary relationships among our
natural foodstuffs," in Journal of American Medical Association, vol. 68,
1917, p. 1379.
Tredgold, A. F. : Mental Deficiency. William Wood & Co.. New York,

1914, pp. 291-295.
i Emerson, Wm. R. P., M. D. : "Standardized physical examinations." in

Archives of Pediatrics, vol. 35, 1918, p. 411.

liryant, Louise S. : School Feeding. J. B. Lippincott Co., Philadelphia,
? 1913, p. 147.
() Newman, George, M. D. : Annual Report of the Chief Medical Officer,

Board of Education (England and Wales), 1917-18, p. 128.
Ibid. : pp. 92-93.
Kind-son, Wm. R. P., M. D. : "Class methods in dietetic and hygienic ^

treatment of delicate children," in Pediatrics, vol. 22. 1910, p. 626.
(a) Public health committee, New York Academy of Medicine: "Malnutrition
among school children," in Medical Reco-d. vol. 03, 191S. p. 311.

(19)

Smith, Charles Henclge, M. D. : " Methods used in a class for under-
nourished children, """in American Journal of Diseases of Children, vol.
15, 1918, p. 373.

Kantor, John L., M. D. : " Experience with a class in nutrition," in New
York Medical Journal, vol. 108, 1918, p. 241.

Wilson, May G., M. D. : "Report of the Cornell nutrition class," in Ar-
chives of Pediatrics, vol. 36, 1919, p. 37.

Manny, Frank A. : " Nutrition clinics and classes," in Modern Hospital,
vol. 10, 1918, p. 129.

Mitchell, David, M. D. : " Malnutrition and health education,'" in Peda-
gogical Seminary, vol. 26, 1919, p. 1.

Roberts, Lydia : " A malnutrition clinic as a university problem in ap-
plied dietaries," in Journal of Home Economics, vol. 11, 1919, p. 95.

Smith, Charles Hendee, M. D. : How to Conduct a Nutrition Class. Child
Health Organization, 289 Fourth Avenue, New York.

WASHINGTON : GOVERNMENT PRINTING OFFICE : 1919

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