Malnutrition is the condition that results from taking an unbalanced diet in which certain

nutrients are lacking, in excess(too high an intake) , or in the wrong proportions.[1][2] A number of
different nutrition disorders may arise, depending on which nutrients are under or overabundant
in the diet.

The World Health Organization cites malnutrition as the gravest single threat to the world's
public health.[3] Improving nutrition is widely regarded as the most effective form of aid.[3][4]
Emergency measures include providing deficient micronutrients through fortified sachet
powders, such as peanut butter, or directly through supplements.[5][6] The famine relief model
increasingly used by aid groups calls for giving cash or cash vouchers to the hungry to pay local
farmers instead of buying food from donor countries, often required by law, as it wastes money
on transport costs.[7][8]

Long term measures include investing in modern agriculture in places that lack them, such as
fertilizers and irrigation, which largely eradicated hunger in the developed world.[9] However,
World Bank strictures restrict government subsidies for farmers and the spread of fertilizer use is
hampered by some environmental groups.[10][11]

Malnutrition and poor academic performance: critical

contributions

Sandra Maria Sawaya

ABSTRACT

This article rises some contributions from psychology to the reflections on malnutrition and
low school performance, through an analysis of some statements on the causes and
consequences of malnutrition to child development as well as schooling of lower classes
children. It analyses the assumptions that low performance at school of a great number of
students in Brazil would be explained by the presence of malnutrition, current or previous.
It critically discusses the investigative methodologies and analysis which presented
questionable conclusions that children who are victims of malnutrition suffer from cognitive
and linguistic deficiencies. Finally, it provides survey results, showing the need of reviewing
these assumptions, since they continue to guide policies and practices on education and
health, rendering impossible the solutions to school problems.

Keywords: Malnutrition and Learning, Lower Classes and Poor academic Performance.
 

THE OBJECTIVE of this article is to provide some contributions from psychology to the
reflections about malnutrition and poor academic performance, based on the analysis of
certain statements dealing with the causes and consequences of malnutrition to child
development and to the schooling of lower classes children. First, we will analyze the
assumptions that poor academic performance of a great contingent of children enrolled in
schools all over Brazil would be explained by current or previous malnutrition, and that
school snacks would solve the problem. Next, we will present critical arguments to the
commonly used investigation and analysis methodologies. the results of those investigations
lead to the questionable conclusion that all the malnourished children suffer from physical
and mental deficiencies that would jeopardize their learning. Besides, surveys show that the
very actions used to fight the school problems are based on the assumption of cognitive and
linguistic deficiency of poor children. Besides, we will point to the need to review those
assumptions, so that the programs to fight malnutrition and school failure can be effective.
Finally, we will present proposals to review the conceptions and the actions that, instead of
solving the school problems, make them even more serious.

It has often been stated that malnutrition – one of Brazil’s most serious social problems – is
also one of the great responsible for poor academic performance. In the 1990’s, certain
publications (cf. Ribeiro, 1991, 1993) already pointed out that about 50% of the children
enrolled in the first grades of the elementary school failed all over the country.

The origin of those ideas goes back to a tradition of humanities studies of the 1960 ’s, a
period when the lower classes began to have greater access to public schools. The studies
of that time try to show that the poor academic performance of the lower classes children
resulted from deficiencies in their biopsychosocial development.

Known in the educational environments as cultural deprivation or cultural scarcity theories,

they search for the reasons of the poor academic performance in the children themselves
and in their precarious life and eating conditions. They state that the lower classes children
fail in school because they have cognitive deficit, motor, perceptive and emotional
development delay, and language deficiencies. The deficiencies pointed out would be the
causes of the poor performance by those children in the school learnings, in the intelligence
tests and also of the absence of behaviors expected by the school (discipline, concentration,
motivation for learning, etc.).

Both the causes and consequences of malnutrition for the children’s development may be
analyzed according to two different perspectives. The first one analyses the malnourished
child, his or her family structure and his or her life conditions through the application of
closed interviews, tests and instruments that are standardized according to an expected
development scale in each age group. The most well-known are the anamneses, the
psycho-diagnostic tests that evaluate intellectual and emotional development, school
learning and linguistic skills. the individuals are analyzed "as they are". therefore,
malnutrition is considered as an individual problem, which can be investigated outside a
broader context, that is, isolated from the social, economic and political conditions of its
production.
Another way to get to know both the causes and the consequences of malnutrition to a
considerable share of the Brazilian poor children is to try to understand them as a result of
the conceptions and actions established between the different social groups and the
institutions from the social, economic and political relations that structure the Brazilian
society. We will adopt the latter perspective in this article.

Brief Brazilian feeding status scenario

According to data from the National Household Sample Survey / PNAD of 2001, 74.6% of
the economically active population earns up to three minimum wages; of those, 35.7% earn
up to one minimum wage and 24.1% earn less than one minimum wage.

If we compare the purchasing power of a minimum wage (MW) to the basic-needs grocery
package, we notice that the wage earners can’t afford it with what they earn. Its cost in
1996 ranged close to 100% of the minimum wage. In 2002, the minimum wage
corresponded to 77% of the package’s price, according to Dieese. According to the data
from PNAD of 2001, it can be verified that, in the Northeast, the workers who earn the
equivalent of one minimum wage or less represent 41% of the occupied labor force. In
other words, almost half of that region’s population can’t afford a basic-needs grocery
package, since the MW is enough to pay only for a part of its foods.

Besides, when they analyze the items of the basic-needs grocery package idealized to serve
as a reference to calculate the minimum wage, Moyses & Collares (1997) reveal that its
composition is not enough to feed the idealized family (a couple and two children) as a basis
for the calculation. The basic-needs grocery package idealized by the law includes: 6 kg of
meat; 4.5 kg of beans; 3 kg of rice; 7.5 l of milk; 1.5 kg of wheat flour; 6 kg of potatoes; 9
kg of tomatoes; 6 kg of bread; 600 g of coffee; 3 kg of sugar; 750 g of oil; 750 g of butter
and 7.5 dozens of bananas. Dividing that package by the four people, in relation to the most
calorific foods, we have: 50 g of meat per person per day, as well as two glasses of milk and
three bananas per person per day (ibidem, p.230).

In short, an insufficient basic-needs grocery package is almost inaccessible to a

considerable share of the Brazilian workers. For that reason, the statements that indicate
incorrect eating habits, the inexistence of eating patterns, the lack of care by the mother or
neglect in the children feeding as the malnutrition causes in Brazil must be reviewed. In
other words, malnutrition is caused by a social exclusion scenario that turns the access of a
considerable share of the population to adequate feeding inviable.

Another set of explanations that became the object of scientific challenge involves, on the
one hand, the confusion between two distinct concepts – hunger and malnutrition are used
as synonyms –, and, on the other hand, the statement that malnutrition affects all Brazilian
poor people.

Confusion between hunger and malnutrition

The conceptual confusion between malnutrition and hunger is present in the statements by
teachers and health practitioners and even in the public policies (cf. Moyses & Collares,
1997). It is stated that every poor child starves and/or is malnourished, when people try to
explain his or her learning problems at school. They still believe that school snack will
indeed solve the problems.

The confusion is not limited to a conceptual mistake. It also conceals the fact that a reduced
number of currently or previously malnourished children patronize school. In the 1980 ’s,
studies (Moyses & Lima, 1982) already registered that only between 10% and 15% of the
children enrolled in the public schools were currently or previously malnourished. However,
those children suffered from moderate or light malnutrition. In other words, they were not
among the children so seriously malnourished that this situation would have left irreversible
damages in the central nervous system. those children often die.

Moyses & Collares (1997) explain: hunger is the basic need for food which, when not
fulfilled, reduces the availability of any human being for both the daily and the intellectual
activities. However, once that need is fulfilled, all its negative effects cease, without any
damages. Malnutrition, in turn, occurs when hunger goes on in such intensity and for such a
long period of time that they start to interfere in the body’s energy supply. to keep its
metabolism working, the body adopts several "expenditure contention" measures. In the
lighter cases (the so –called level 1 or light malnutrition), it reduces the growth rate: the
body maintains all the metabolism normal at the expense of sacrificing the growth rate
(ibidem, p.232)

But the children who suffer from serious malnutrition and, because of it, from neurological
impairment are not in school, among other reasons, because the infant mortality rate is
very high. thus, the school snack offered does not reach them. It has also been insufficient
to change the nutritional status of any child. In 1986, each child received, in the food
supplement program, only 12 kg per year (Moyses & Collares, 1997). We know that the
school snack can solve, however, the "daily hunger", that is, the empty stomach problem,
which jeopardizes any human being’s awareness capacity and disposition to learn.

Nevertheless, how pertinent is the statement according to which malnutrition causes

disorders in the intellectual development of the children and, as a consequence, turns
learning inviable?

Malnutrition and development disorders

Studies (Dobbing, 1972) show that only in the serious malnutrition cases there are changes
in the central nervous system (responsible for the intellectual functions of the individuals)
that fall upon the brain’s anatomy (reduction of the weight, size, volume, number of cells,
amount of myelin, etc.). But those anatomic changes don’t allow for any conclusion about
the effects on the functioning of the brain.

It is not known how the nervous synapses produce intelligent actions. There is no consensus
about how the environmental stimuli cause functional changes in the brain (if there’s an
increase of nervous junctions, if they activate skills that would be activated if there was no
opportunity for use). In short, it is not known to what extent the environmental stimuli, the
cultural and educational opportunities change the nervous system. However, studies (Stein
et al., 1975) show that children who have suffered from serious malnutrition early in their
lives and, therefore, had irreversible changes in their nervous system, but weren’t poor, and
were tested when they were 18 years old, revealed an intellectual development equivalent
to that of the normal adolescents, and presented good academic performance.

Therefore, it is necessary to question the intellectual performance evaluation methods of the

currently or previously malnourished children, to avoid the mistaken conclusion, in such
countries as Brazil, that the children are deficient.

The evaluation of the individuals’ intellectual capacity

The starting point of the current criticisms is the following question: Is it possible to
evaluate someone’s intellectual capacity (Collares & Moyses, 1996; Patto, 2000), or do we
measure only the use of those skills, adopting as standard-norm the uses established by the
school knowledges? Today we know that the potential that we believe to be measuring is,
indeed, built in a complex interaction process between the individual, since his birth, and
the social environment in which he lives (Vygotsky, 1984). In turn, the social environment
results from a historical structure that defined the social actions, the human relation
manners and the set of knowledges present there, as well as the access and use conditions
of those knowledges, unevenly distributed.

Is the performance difference in the intelligence tests, the results of which point to a great
contingent of children with bordering or below average IQ, a sign of incapacity of the child
or a product of the social inequalities? The inequalities are what hinder the access of the
lower classes children to a quality education, to the scientific knowledges, to the ways of
thinking produced by the school.

Those attempts to evaluate human intelligence disregard the development conditions of the
investigated skills: the school knowledges and the school work to organize the mental
schemes to assimilate the contents, verified through the set of questions and problems
proposed by the tests. Thus, before the question of one of the most used tests to evaluate
the intellectual capacity of the children – Who was Gengis Kan? –, we readily hear the child
state that he or she couldn’t answer that, since he or she hadn’t learned anything about him
at school.

The socialization processes that make up the individual and shape the expression forms of
the human intelligence and their uses are not universal. there are universal biological
characteristics such as the human capacity to speak (Cagliari, 1997), but the expression
forms of those linguistic skills are modeled by the linguistic group to which the individual
belong, by the nature of the social interactions and by culture. There are language styles,
distinct uses of the linguistic codes due to the different contexts and there is a social status
attributed to certain language uses, improperly evaluated as a superior skill (Bourdieu,
1983) and often identified as a sign of high IQ. thus, what is evaluated are the expression
forms of the language and of the intelligence, mediated by the cultural values, by the
available knowledges and by the senses attributed to them by the culture to which the
individual belongs.

Most of the malnourished children are miserable, and have no access to the cultural goods
and to the benefits of society. Therefore, it’s no longer possible to separate the effects of
malnutrition on the children’s body from the negative effects produced by the
precariousness of life in which they are immersed.
To what extent, however, the material misery condition, the lack of access to the school
knowledges and the social inequality jeopardize the cognitive skill of those families and their
children, their abilities to speak, think, argue, struggle for their own lives, build an
honorable life, educate their children and feed them?

The several material shortages and children malnutrition

The proposition that poverty causes linguistic, cognitive and emotional deficiencies has
already been exhaustively discussed, when applied to explain the poor academic
performance of the lower classes children (Cunha, 1977; Houston, 1997; Patto, 1990, 1997;
Sawaya, 2001, among others). those authors claim that there’s a lack of solid scientific
evidences to attribute to the material shortage and to the precarious life conditions of the
families and their children from the lower classes a supposed deficit or delay in the cognitive
and linguistic development and to relate the latter to the causes of the children ’s poor
academic performance. However, those discussions didn’t prevent the study of the intra-
school causes in the production of the schooling difficulties of those children, to be
neglected for a long time.

A reorientation in the focus of the surveys about the causes of the academic failure of the
huge contingent of poor children revealed the countless school mechanisms and processes
responsible for learning difficulty (Patto, 1990). the difficulties identified in the pedagogical
action no longer allow us to state that the school problems are problems of the poor
children and their families, considered in an isolated manner. Among other factors, the
assumption that the students don’t have certain skills that they often do have, the
expectation that the clients don’t learn, the bureaucratic obstacles to achieve the works at
school – such as the constant displacement of the teachers throughout the school year, the
frequent changes in educational programs and projects, the excessive hierarchy of the
functions and the authoritarian relations that circulate through all levels of the school
structure, besides the low remuneration of the teachers and their professional devaluation –
produce a "failurization of the pauperized student"(Patto, 1990).

However, that reality is not well-known (Azanha, 1995), even among health practitioners to
whom the children with difficulties at school are directed. Even with a high professional
background level, such as in the case found in a large town of the São Paulo state inland,
the psychologists interviewed in the survey (Cabral & sawaya, 2001) ignore the school
reality and still attribute the supposed deficiencies of the children to their poor academic
performance.

In a study that we carried out, we registered that 63% of the practitioners have
specialization and graduate courses in their respective fields: psycho-pedagogy and clinic
psychology. among them, 26% have a masters degree and 5%, a doctorate degree (Cabral
& Sawaya, 2001). Asked about the complaints that lead the schools to direct, every year,
many children to the psychological attendance services, they invariably allege problems of
the child and his or her health conditions, feeding and family structure problems. school is
secondary in the evaluation. When they do refer to it, they seldom even mention the intra-
school causes that produce the difficulties presented and that have direct repercussion on
the behavior of the children, such as the constant teacher change in a same class during the
school year.
The inadequacy of the diagnoses centered in medical issues to explain the learning
problems of the great contingent of initial grades students, directed to the health services,
and of the adopted measures, has also already been identified (Moyses & Collares, 1997).
But the assumption of the existence of neurological diseases still lead to the countless
directions of children with poor academic performance to computerized tomography exams
(used to identify brain damages or bad functioning) and psychiatric treatments.

We found children enrolled in special classes (destined to people with special needs) to
whom microcephaly is attributed without any medical diagnosis proof: the only symptom
verified is "being disorderly, not being interested in school". Many times, we find in the
classes children who are indifferent, sleepy, cognitively confused, because they are under
the effect of psychiatric drugs without a proved diagnosis.

Also widely questioned by the linguists are the complaints, very frequent both in the health
services and in school, according to which poor mothers and children suffer from language
impairments, since nobody understands what they say or because they don ’t follow the
indications of the doctors, nutritionists, psychologists and social assistants. Such statements
are based on assumptions that are not scientifically supported in linguistic studies (Cagliari,
1997; Houston, 1997). The mistakes identified as a linguistic deficit are nothing but
phonetic and syntactic errors, and, therefore, are not linguistic structure failures that could
jeopardize the understanding and the logical framework of the statements. those authors
also believe there is no pertinence in the statements according to which a restrictive
linguistic performance, in which few words and simple structures are used, is a sign of
cognitive impairment. In order to communicate, every speaker uses highly complex and
abstract cognitive processes, and the ability to understand the language overcomes the
verbal performance (Houston, 1997, p.179).

Nevertheless, what are the arguments that explain the restrictive or mistaken
communication – often considered a sign of language impairment – among mothers, health
practitioners and teachers? Besides the linguistic aspect, one must observe other factors
that are at stake in those contexts, since we know that the verbal emission may be
jeopardized in the communicative relations marked by stress, humiliation and failure
situations, such as the school meetings and the medical appointments in which, as a rule,
the mother takes the blame for the child’s malnutrition.

There are humiliating questions that disclose what the mothers want to conceal because
they are ashamed of their own condition, also seen as personal guilt. Those are the
questions such as: What is there to eat at your house? How many meals do you eat per
day? Do the children play? Do they own toys? The mothers of the malnourished children
that we investigated arrive at the interviews (requested by us) excusing themselves,
reaffirming discourses that they heard and that blame them, but that also denounce the life
condition in which they find themselves – "I think she got malnourished because I couldn ’t
watch her and she stayed at my neighbor’s house, and with my husband unemployed, I had
to go out and work in order not to die of starvation."

We found nurseries, pre-schools and schools where the mothers have neither names nor
identity, they are "mothers" received in the halls, in the courtyard, in the principal ’s office,
called in to listen to complaints about their children, to listen to death sentences: you didn’t
feed your children well, you were careless and, for that reason, today they have a hard time
at school, they don’t learn, their development is delayed. Directed to the special class, they
constitute a group of discredited children, in whom the school is no longer interested.
Is the supposed low self-esteem of those mothers an intrinsic problem, a personality trait
that a therapeutic work could solve? Or is it a result of the relations that the society and the
social institutions (school, health, etc.) establish with them on a daily basis? Could the
therapeutic work improve the affective and emotional conditions, their relations with the
others and their lives, without the improvement of the concrete social relations that
produced such situation, in the health services and in the schools? In other words, would it
be possible to change the mothers’ situation without changing how they are received in the
schools, in parent meetings, with reprimands and accusations?

The factors often considered as causes of the high malnutrition and poverty rates

– for example, few cognitive resources of the mothers, their affective problems and their
absence of family structure – are questioned by the very knowledge developed in the direct
contact with those families and their children, in the neighborhoods. the extended familiarity
with the researcher – who avoid long hours to listen to the stories of the families, their
explanations about life, their difficulties and their survival strategies – reveal a distinct
universe from what would be characterized by shortage in all senses.

The same children who are identified at school as suffering from development disorders and
from the lack of logical thinking can be found working in the fair, selling products in the
traffic lights, changing money, making math operations without a calculator (Carraher et al.,
1982). They invent stories, make puns, tell jokes, use metaphors and resort to folk or
country songs to dissuade the adults from an aggression, to get food, to make a community
of listeners laugh, since they must conquer their space and their survival. They only don’t
use language that proves slyness and intelligence, but they also use the word as a resource
in the quest for their survival in very adverse conditions (Sawaya, 2001).

In the same way, the normative models used to evaluate the families, which designate
them as without structure since they don’t correspond to the model of the nuclear family,
are questionable (Mello, 1992). the model – considered as ideal and source of all the mental
health virtues and guarantees – prevents us from seeing that the family rearrangements
guarantee subsistence and the affective ties. As a true survival strategy, the reorganization
of the family nucleus – by including relatives, pals and other possible relationships –, more
than revealing anomy or lack of structure, reveal possibilities in the support, in the
preservation of the affective ties, possibilities of changes and mutual help among their
members.

Far from stating that misery has no devastating effects on the life of the individuals, we are
calling the attention both to the social exclusion mechanisms, and to the strategies used by
the poor families in their daily struggle to survive and to have a worthy life. The
understanding of the social processes that generate exclusion and of the ways to face
adverse life conditions of the lower classes families must be, from that perspective, the
starting point for the social actions against poverty and malnutrition.

Some data reveal that, despite the countless problems that population faces, in the last few
decades there was a decline in the malnutrition rate in the population under five years old
(ENDEF,1 1975; PNSN,2 1989). The explanations that are often attributed, in the health
area, to the decline of the malnutrition rate in Brazil are the rural exodus and the greater
access to the health services, even though during the same period there was an increase of
poverty and of unemployment in Brazil. Thus, the improvement of the malnutrition rates
can’t be explained by the improvement in the income conditions of that population. Rather,
the decline must also be considered according to the countless survival strategies that the
low income populations find to avoid hunger and absolute misery, among which some have
already been mentioned, such as the family rearrangements.

However, if we can already rely on survey results that reveal the limits of some statements
about malnutrition and the poor academic performance, allowing for a broader
understanding of the problem, the great challenge is to find strategies that provide a
change in the conceptions that still guide educational policies, attendance programs to poor
families and instruments used to know them.

It’s in this sense that we have tried to move in recent years, be it through the qualification
of teachers or through the development of projects in the teaching units themselves.

For an educative project among education and health practitioners,

parents and children

Our proposition is a different approach to the school failure problem. The intervention
projects to fight it must emphasize not the individuals alone, but the relations, the
practices, the conceptions that develop in the scope of family/neighborhood/health and
academic institutions, supported by a critical reading of the society in which they are
included (Sawaya, 2001, 2002a).

The families are part of a broader context. They live in a neighborhood and interact with
institutions that, in turn, relate to them according to conceptions that guide their actions.
the behaviors and the relations that the practitioners verified in the mothers and in the
families ("there was no pre-natal care", "she doesn’t take her medicine", "she doesn’t follow
the diet proposed by the health unit", "she resorts to midwifes", etc.) may only be
understood and changed when the multiple processes that produce the conditions of the
families are considered. Because survey data reveal that, many times, the very relations
established between public institutions and poor families contribute with the verified ideas
and behaviors: lack of hope, low self-esteem, resignation, resulting from the sense of guilt,
of the lack of qualification, of the humiliation, of terrifying statements ("your son has
development disorders", "he’s not learning, he has no logical thinking", etc.).

The mother and the child are characters involved in several circumstances and actions
which lead to malnutrition. In general, the role of the practitioner is limited to punctual
interventions, centered in the nutritional re-education, in the development of eating and
hygiene habits, as if those actions were enough for the social reintegration of the mother
and the child. The attempts to develop positive behaviors are often based on the
assumption that they don’t exist. The punctual actions eventually don’t foster the
questioning of the very quality of the academic and health services offered to the low
income population, to the extent that they ignore the multiplicity of social, economic and
political factors involved in the production of malnutrition and in the low educational quality.

A first issue that teachers and health practitioners must face is the development of a critical
view of the role they play next to the poor populations and to their malnourished children
and/or with poor academic performance. We have seen that, even though we can already
rely on a body of critical knowledges about the approach and acting forms next to those
populations, the ideas that still guide many actions go in the direction of blaming and of
taking for granted the ignorance of the mother and the lack of family structure,
transforming the assumptions in facts and identifying them as sources of the children ’s
problems. If, on the one hand, according to our experience, the review of those ideas is
considered essential for practical changes to occur, on the other hand, it reveals itself to be
ineffective when it is implemented only by means of qualification courses.

One of the work strategies that we have been using to qualify teachers is to foster
reflections in the schools and neighborhoods themselves, where the families, the teachers,
the students and the technical team are heard. the traditional interview and observation
techniques, such as the tests, the anamneses and the closed interviews, are substituted for
orientations brought according to anthropological studies which, in school psychology, has
been done based on surveys such as those carried out by ezpeleta & Rockwell (1989),
among others.

The investigation of the poor academic performance causes, as well as of other problems,
must be done by plunging into the daily life of the teaching institutions and knowing directly
the people involved, in their neighborhoods, in their houses, in their relations with the
neighborhood and with the public institutions. By means of the extended familiarity and of
the creation of dialogue spaces, we identified the presence of biases against poor families,
which become resources used by the teachers and by the school to free themselves from
the blame that falls upon themselves. An easy target of an education that doesn’t produce
results, the teachers appoint the mother, the family that they often don’t know and the
supposed malnutrition of the children as the causes of the academic problems.

To the discovery that, at school, the act of directing the children to the health services is
often motivated by indiscipline complaints, it should be added the verification that, in the
health services, the children undergo not only psychological exams, but also medical exams
that identify doubtful diseases.

The punctual analyses and the often hurried diagnoses, which result from endless lines in
the health services, go back to the school as diagnoses that confirm the previous
hypotheses: those are children with problems and impairments, which justifies the act of
directing them to reinforcement programs, acceleration classes, special classes, therapeutic
attendances, etc.

Countless reports of those stories and of the explanations associated to them reveal a
profound lack of knowledge of the real causes of the schooling difficulties of the poor
children, such as the constant class and school change and the high teacher mobility
throughout the entire school year, among so many other aspects already identified by many
studies (Patto, 1990; Machado, 1994; among others).

So, if the investigation of the causes of the school failure made us refer to the conceptions,
relations and practices present in the school institutions and in the society, the debate on
malnutrition turns necessary for us to study the broader context that produced it. Thus, we
found cases in which the malnutrition of the children occurs in a complex context, with such
situations as the family’s eviction from the slum tenement, flood in the wooden shack,
unemployment, the choice between buying a plot and feeding the children and, in addition
to that, the extended breastfeeding due to the lack of resources to feed everybody. The
eating inconstancy and the irregularity of certain foods, such as meat, might not be a
passing episode, but are related to the financial impossibility to buy the foods and prepare
them.
For that reason, if the school failure is produced by school processes that create difficulties,
malnutrition can also be generated by processes that produce difficulties. For example, we
verified that the explanation for the fact that many pregnant women and adolescents don’t
do the pre-natal exam can’t be generalized in statements about disdain for th e medical
services, lack of interest, ignorance or undesired pregnancy. The low frequency in the health
services can also be associated to the conflicting relations between the health units and the
poorest families, to the biases against people who live in slums and suspect groups (drug
dealers and consumers) and to the precariousness of the health services (Sawaya, 1992).

In our journeys through the neighborhoods, in the visits we made to the families, in the
contact with dwellers associations, with neighborhood leaders – trying not to avoid the
occasional meeting with the drug trafficking leader, with the crook’s family, etc. –, we
found, however, groups of women organized in mothers’ clubs, in neighborhood
associations, in organizations to fight for land and home, which meet in the parish, in
dweller associations, or even in their own homes to discuss their problems and help each
other mutually, in an intelligent and creative manner (Sawaya, 1992).

On the other hand, we found teaching institutions isolated by walls and gates, transformed
into jails, protecting themselves from the population that patronize them and, often, without
noticing that the violence and the social exclusion are caused by the school practices
themselves.

Finally, the systematic hearing job next to the several groups involved in the issues of
malnutrition, poverty and school failure reveals an unknown and unique universe, in which
poverty produces deep signs, but has different shades in the different groups. It is
necessary to know that reality to review the practices, relations and conceptions that, many
times, jeopardize the propositions to fight poverty, low schooling and malnutrition.

Final thoughts

1. The explanations about how malnutrition and its consequences determine the
development and the learning of the children must be reviewed based on the knowledge of
the social exclusion processes, operated by the practices and conceptions that guide acting
practitioners in the schools and in the health services.

2. The instruments used to get to know the poor population, its cognitive and affective
resources must be reviewed, as well as the manners by which the population overcomes
hunger and misery and manages to survive must be known.

3. The projects for the qualification of acting teachers and of health practitioners must
include the reflection about the intra-institutional mechanisms that produce the difficulties
found and generate the social exclusion.

Notes
1. National Family Expense Survey, made by IBGE. Project assisted by FAO (Food and
Agriculture Organization of the UN), 1975.

2. National Survey on Health and Nutrition, made by IBGE, together with Inan and Ipea,
1989.

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Received on 5.15.2006 and accepted on 6.16.2006.

 
Sandra Maria Sawaya, graduated by the Institute of Psychology of the university of São
Paulo, is a master and doctor of the Department of Philosophy and Education Sciences, area
Psychology and Education, in the College of Education of the same university. @ –
smsawaya@usp.br / sandrasawaya@yahoo.com.br.
Translated by Rodrigo sardenberg. the original in Portuguese is available at
http://www.scielo.br/scielo.php/script_sci_serial/lng_pt/pid_0103-4014/nrm_iso.

Abstract
The following paper and its accompanying paper (Grantham-McGregor SM, et al. Effects of
health and nutrition on cognitive and behavioural development in children in the first three
years of life. Part 2: Infections and micronutrient deficiencies: iodine, iron, and zinc. Food Nutr
Bull 1999;20:76-99) review the literature on the conditions that are prevalent and considered to
be likely to affect child development and are therefore of public health importance. The reviews
are selective, and we have generally focused on recent work, particularly in areas that remain
controversial. The reviews are restricted to nutritional and health insults that are important in
the first three years of life. Where possible, we have discussed the better studies. This paper
considers the effects of low birthweight (focusing on small-for-gestational-age babies) and early
childhood protein-energy malnutrition on mental, motor, and behavioural development. We have
also included a section on breastfeeding because of its importance to child health and nutrition
programmes.

Introduction
In developing countries, millions of young children suffer from nutritional deficiencies and
frequent infections. There is now a large and increasing body of evidence to indicate that
nutrition and health affect children’s cognitive, motor, and behavioural development, both pre-
and postnatally. The impact of a biological insult depends on the stage of a child’s development,
as well as the severity and duration of the insult. However, because nutritional deficiencies and
infections frequently occur together, the problems resulting from any one insult may be
exacerbated by the presence of another, and the effects can be cumulative.

The situation is further complicated in that children who suffer from nutritional deficiencies and
infections usually come from poor sociocultural environments and suffer from a myriad of
deprivations and disadvantages that could themselves be detrimental to intellectual and
behavioural development [1, 2]. These conditions include poor physical resources, such as
overcrowded homes with poor sanitation and water supply, few household possessions, and low
income. In addition, parents may have limited education and intelligence, and little knowledge of
child development and the importance of play [1]; they may also suffer from depression [3].
Stimulation in the home is generally poor, with few toys or books and infrequent participation by
the parents in play activities. Since nutritional deficiencies nearly always occur in the presence of
these disadvantages, demonstrating a direct causal link between poor nutrition and poor
development is difficult and requires a randomized controlled trial in which nutrition
supplementation is given to undernourished children. Although establishing independent
causality is important, it may not reflect the real-life situation, because there is increasing
evidence that interactions exist among environmental conditions, a child’s biological status, and
various biological insults. Thus, in order to understand the true situation, these many factors
should be studied together.

In studies evaluating the effects of poor nutrition on a child’s development, investigators

traditionally focus on motor and cognitive development. However, it is critical to evaluate social
and emotional development as well, because these factors may be equally, if not more, important
to an individual’s success in life.

Low birthweight
Almost 25 million low-birthweight (LBW) infants (<2,500 g) are born each year, 95% of them in
developing countries [4]. In developing countries, LBW infants are more likely to be born at
term than those in developed countries and more likely to be small due to intrauterine growth
retardation (IUGR) secondary to maternal undernutrition and infection [5]. The diagnosis of
IUGR requires longitudinal measures of intrauterine growth. As these are rarely available in low-
income countries, we will restrict this review to infants born at term but small for gestational age
(SGA).

A recent review of 80 studies, mostly in developed countries, showed that LEW children
generally have poorer levels of development than normal-birthweight (NEW) infants [6]. Fewer
studies exist of SGA infants, and they suffer from many design problems. Probably the greatest
problem is that researchers have used different definitions for SGA, and there is no generally
accepted definition, although the World Health Organization (WHO) recommends using the 10th
centile for gestational age [7]. There are also several confounding variables that are frequently
not taken into account adequately. SGA babies have a greater incidence of perinatal
complications than NEW babies [8,9], which may detrimentally affect their subsequent
development [10]; they also come from poorer homes than NEW children and are less likely to
be breastfed. A further problem is that samples of SGA children have often been small and had a
large percentage of drop-outs [11, 12] that is often biased [13]. The babies from the poorest
homes and those who have the poorest development are the most likely to drop out. It is
surprising that so few studies have been undertaken in developing countries, where SGA infants
are more common and the children are exposed to more deprived environments, so that their
development may be very different. All aspects of the development of SGA babies were recently
reviewed at a meeting of the International Dietary Energy Consultative Group [14-17]. SGA
infants were found to suffer from more infections and higher mortality rates in the first year of
life than NEW babies [18].

Studies of children in the first two years

Most studies evaluating SGA children before 12 months have failed to find differences in
developmental levels between SGA and NEW infants [19-22] (table 1) [15, 19-24]. However, a
recent Brazilian study showed that SGA babies scored significantly lower on the Bayley mental
and motor subscales at 6 months and that the difference increased by 12 months [15].
Pour other studies compared SGA and NEW children between 12 and 24 months, and all found
deficits in the mental development of SGA children [20, 21, 23, 24], but in most cases the
differences were attributed to particularly vulnerable subgroups. For instance, in a study of
American toddlers, only male or African-American SGA children showed a deficit [23]. Others
reported that the deficits were almost entirely found in children who had neonatal asphyxia or
congenital anomalies [24], and that children with birthweights below 2,300 g were entirely
responsible for the deficits in the SGA group [21]. In the remaining study, the difference
between groups was only significant in those who had appropriate ponderal indices (API) at
birth, indicating that the foetus may have been undernourished in early pregnancy [20].

Studies of children two to seven years of age

Some studies followed the children for several years, and the findings sometimes changed with
the age of follow-up. In American children who were assessed at 4,5, and 7 years of age, IQ,
language development, and reading readiness were worse in LEW children when gestational age
was controlled for, even without differences at 8 months of age [19]. Similarly, SGA
Guatemalan children who had not been different from NEW children before 12 months had
significantly poorer developmental levels in their second year and had lower scores on a
cognitive battery verbal factor score than the NEW group at 3 years of age [20, 26]. Differences
between the groups disappeared on subsequent evaluations at 4 and 5 years [26].

Details of studies of children 3 to 8 years of age, mostly from developed countries, are given in
table 2 [11,17, 20,26-31]. Children who were SGA generally performed worse than those who
were NEW in tests of cognition [20,26], IQ[11,17,28-32], and language [27]. In two studies the
SGA group performed worse than the NEW group, but the difference did not reach significant
levels, perhaps because the sample sizes were small [28,31].

Studies of children 7 to 17 years of age

Hack’s comprehensive review [16] identified 12 long-term follow-up studies of SGA children
under 18 years of age, all but one [33] from developed countries. All studies in which IQ was
measured showed that SGA children had lower scores [34-36] or higher rates of mental
retardation [37] or learning deficits [38] than adolescents who were NEW, although the
differences were sometimes small and not significant [39]. Studies of older adolescents or adults
have had inconsistent findings and suffer from a large number of drop-outs [16].

The only other study from a developing country in which SGA children were followed up to this
age was in Guatemala; surprisingly, no long-term effects of SGA on cognition were found [40].
It maybe that the definition used for SGA (10th centile for gestational age) is too high for an
index of risk or that undernutrition and other disadvantages in childhood overwhelm the
relatively small effect of SGA. One study attempted to address this point [31]; Indian children
who were chronically undernourished and were LEW were compared with similarly
undernourished children who were NBW. The groups’ scores on cognitive tests were not
significantly different, but the LBW group’s scores were consistently lower, suggesting that a
small disadvantage remained. However, further research on this point is needed for more
certainty. Both groups’ scores were markedly lower than a third of the adequately nourished
group.

Malnutrition on Children

Causes, Signs, Symptoms

It is an impairment brought about by inadequate or excess intake of food. Protein-energy

malnutrition is the most common type in the Philippines due to inadequate intake of body-
building and energygiving foods like milk, fish, meat, oil, rice, root crops and the like. Infections
like measles, whooping cough, infectious diarrhea, and tuberculosis are common illnesses that
lead to malnutrition. Children in poor living conditions and not breast-fed have greater tendency
to become malnourished since they become sick more frequently. Poverty, unavailability of
food, ignorance, and rapid population growth are among the social causes of malnutrition.

First degree (mild) and second degree (moderate) are more common than the third degree
malnutrition.

Severe malnutrition occurring early below 12 to 18 months usually leads to marasmus form (skin
and bones). Kwashiorkor is another severe form of malnutrition.

Signs of Severe Forms of Malnutrition

A. Marasmus

1. very thin body, bones prominent

2. wrinkled and dry skin, especially in the buttocks and arms

3. hair is thin and soft

4. face like an old man's

5. cries often

B. Kwashiorkor

1. legs and hands are swollen with water (edema)

2. skin has dark brown to black patches which can be peeled off

3. hair is thin and can easily be pulled out

4. face is flabby or moon-faced

5. sad; does not smile

6. belly is enlarged

7. very slow learner

Treatment

1. Breast-feed the baby 1 to 2 hours after delivery. Continue breastfeeding as long as the mother
has milk. Start supplementary feeding when the baby is 4 months.

2. Do not use condensed milk as breast milk substitute.

3. For severe cases, bring the child to the nearest health center, hospital, or clinic. Consider this
as an emergency. The child usually has diarrhea or lung infection. Avoid delay of treatment.
After emergency condition is controlled, treatment and nutrition rehabilitation must be continued
at home.

4. Treat the existing infection or illness and prevent its recurrence.

5. Prepare nutritious and appetizing food.

6. If a child has no appetite, encourage small but frequent feedings. Do not force him or her to
eat.

7. Minimize giving junk foods, soft drinks, and artificially colored or flavored snack food with
"empty calories."

8. Encourage the child to have regular meals. Snacks should be given 2 hours before meals.

9. Provide stimulating materials to hear, see, touch, taste, and smell.

10. Provide a warm, loving environment.

11. Seek help and support of community leaders.