Childhood is considered a transcendental stage in man’s evolutionary process, characterized by two phenomena: growth and development, for which adequate nutrition is essential.
According to Unicef by malnutrition in childhood is the most regretted by society, since at this stage the greatest impact suffered by the child’s brain, in which irreversible metabolic and structural alterations would occur, however, child malnutrition is not only a problem of lack of food, it is a deeper social conflict, which must be taken into account when providing solutions.
The Corporation for Child Nutrition (CONIN), established in Chile in 1975, aims to recover children from 0 to 3 years of age who have primary or secondary malnutrition. Since 1993, this project has been extended to the province of Mendoza, Argentina, as a CONIN Foundation (Cooperator for Child Nutrition), where this experience was completed by creating Centers for The Prevention of Malnutrition. Currently, this project is developed in different provinces of the country, in Paraguay and soon in Peru, supporting its work in three pillars: teaching, assistance and research.
CONIN develops a strategy of the intervention of great health impact on the low-income population of its area of influence, with a high social impact since it enhances the family and its environment as the basis of the correct physical and intellectual development of the child, together with an adequate supply of nutrients, which allow the child to develop its genetic potential.
Childhood is considered to be a momentous stage in man’s evolutionary process, characterized by two phenomena: growth and development. Adequate nutrition is essential for these phenomena to occur normally.
Nutrition, in turn, is subject to conditioning factors: some fixed, such as the genetic potential of the individual and others dynamic, such as social, economic and cultural factors, which can act favourably or unfavourably. When the balance of these factors is changed, and nutrition is altered, the growth and development of children are interrupted, resulting in child malnutrition1.2.
Malnutrition can be primary when it is caused by a nutritional and/or psychoactive deficiency, and secondary when there is a disease that determines it, regardless of its socio-cultural situation; for example genetic, metabolic, immunological diseases, malformations, which may affect the brain, heart, kidney, liver, etc.3. It is also important to recognize that the effects of malnutrition are valued in the short and long term. Diarrhoeal diseases, dehydration, hydro electrolytic alterations, immunity depression, infections, weight loss, haematological, cardiorespiratory and renal disorders first appear. Later, size deficit and decrease in IQ will appear. Statistics are based on three indicators: weight for age, which measures global malnutrition: size for age, which reflects chronic malnutrition, because low stature is the result of prolonged nutrient deficiency; and weight for size, which measures acute malnutrition.
Depending on the intensity of malnutrition, varying degrees are allowed. McLaren established the following grades: I (mild), II (moderate) and III (severe), according to the percentage of weight loss related to size and age, in mild cases weight loss is estimated to be between 85-90% of ideal, moderate between 75-85% and severe when weight is less than 75% of ideal for size and age 4.
The havoc caused by malnutrition in childhood is the most regretted by society 5 since, at this stage, the greatest impact is suffered by the child’s brain, in which irreversible metabolic and structural alterations would occur6-8.
Malnutrition, in the first few years of life, can affect the individual’s growth. Although it is possible to subsequently achieve an improvement in the adequacy of the size, through a good diet, since the child continues to grow up to 18years 9, these individuals never reach a normal size.
Stoch and Smythe were the first to formulate the hypothesis that malnutrition during the first two years of life, could inhibit brain growth and this would result in a permanent reduction in its size and low intellectual development10-12; the first two years of life not only correspond to the period of maximum brain growth but at the end of the first year of life, 70% of the adult brain weight is reached, also constituting, almost the total growth period of this organ 13.
The child with severe malnutrition has a smaller diameter of the skull. Still, it has also been seen that not only does brain growth stop, but there is also brain atrophy, forming a space that is occupied by cerebrospinal fluid. As a result, transillumination is intense. This highlights brain atrophy in malnutrition.
Also, the development of the central nervous system is determined in the first 18 months of the child’s life. If during this time the child does not receive adequate intake of nutrients 16 and sensory stimulation, neuronal development atrophy occurs 17.18, where you can see the differences in the shape and size of neurons and their dendritic ramifications between a normal child and a malnourished child 19.20.
Social deprivation affects a child’s brain development, reflecting on a decrease in intellectual capacity21 that will negatively affect the learning process. Poverty is almost always accompanied by psycho-affective deprivation. The family is usually distorted, not fulfilling normal parental roles. During this time of great learning, when the child begins the exploration of the world around him, he encounters a family environment that does not stimulate his imagination or exacerbate his curiosity, leading to a significant deficiency, which is the lack of verbal stimulation, per se the vocabulary of parents very restricted 22. The child is born and develops in an environment of insecurity 23 and lacks psychic and affective stimulus24. This damage affects not only the inidious25 but the whole society since the main wealth of a country resides in its human capital26.27. Therefore, actions on child malnutrition must be carried out in the first two years of life, through interventions aimed at preventing neuronal damage and preventing malnutrition. After this period, the recovery of the child becomes more difficult, since, in the child, there are permanent consequences, which significantly hinder the learning process in the school 28.
We can then consider malnutrition as a final result of underdevelopment 29, where the child suffers the greatest impact, by relying on third parties for their care and growth 20. This is why child malnutrition is not just a problem of a lack of food; it is a deeper social conflict, which must be taken into account when providing solutions.
Of the nearly 11 million children under the age of 5 who die annually worldwide, half die from malnutrition. The reality in Latin America31.32 is characterized by high percentages of the population living under the poverty line, more than 42.9% according to the report of the Economic Commission for Latin America (ECLAC)33. Regarding the nutritional situation of the Argentine Republic, studies in recent years revealed that the form of malnutrition prevalent in Argentina was the size deficit, with the north being the most affected region, however, the 2001-2002 crisis has impacted on the country’s nutritional situation, where monetary devaluation, the resurgence of inflation, further deterioration in employment indicators and inequality in income distribution created the conditions for a sharp worsening of food situation 34, leading to a serious crisis in access to food for much of the population in early 2002. The population below the poverty line went from 24.8% in 1995 to 54.3% in 200235.
Characteristics of the intervention
The Corporation for Child Nutrition (CONIN), established in Chile in 1975, aims to recover children from 0 to 3 years of age who have primary or secondary malnutrition. Since 1993, this project has been extended to the province of Mendoza (Argentina), as a CONIN Foundation (Cooperative for Child Nutrition), where this experience was completed by creating Centers for The Prevention of Malnutrition. CONIN has set out to eradicate child malnutrition through a work project based on three basic pillars: teaching, assistance and research and for this purpose has extended its borders by creating new centres in different provinces of Argentina, in Paraguay, and soon in Peru. These three basic pillars of CONIN’s work, teaching, assistance and research, are developed in the Recovery Centres for Malnourished Children and in the Centers for the Prevention of Child Malnutrition.
Recovery centre for malnourished children
There is currently only one recovery centre in Mendoza, Argentina. This centre was created following the successful model implemented in Chile, from 197536-38. The creation of such sites is based on the following considerations:
• Malnourished children are immunodeficient, and that is why general hospitals are of great danger to them, as they are usually infected and die there.
• Child mortality from malnutrition in a general hospital is 28%, the internment time of 2 to 3 months and the average hospitalizations per year is 2.8, which totals 120 days of annual detention per child 39.
• Successive re-infections that determine antibiotic therapies, x-rays, interconsulte tests, complementary examinations, nursing, etc., cause the operating cost of malnourished treatment in a highly complex general hospital to approach $300 per day/bed. However, in recovery centres for malnourished children (as CONIN has shown in Chile)39, the internment time does not exceed one and a half month, the recovery is uniform and surprisingly shorter: only 2% require hospital re-entry, the operating cost is $30 per day/bed and, most importantly, mortality drops significantly in its rates, which is around 2%.
The Recovery Center for Malnourished Children in Mendoza, Argentina, can accommodate 50 children from 0 to 3 years of age suffering from primary and/or secondary malnutrition, 2nd and 3rd grade. Children are derived from Primary Care Centers and Hospitals40. Mothers accompany their children during their internment, as the success of treatment consists not only of an adequate intake but also of the affection and stimulation that the child receives. Therefore, special attention is provided to mothers through educational and training activities. During 2004, the number of patients admitted to this centre was 123 children from 0 to 3 years and 106 mothers, and the monitoring and control of outpatients were 123 children from 0 to 3 years and 143 mothers.
Multidisciplinary Centre for the Prevention of Malnutrition
The population serving the prevention centre of Mendoza (Argentina) is very scarce and unstable, presenting high rates of unemployment and underemployment. The income of each household comes mainly from work in brick-making furnaces (the main economic activity of the area), in orchards or eventual work. The houses are deficient and extremely precarious, with a single multi-purpose environment. Sanitary facilities are located outside the house in the form of latrines, usually shared by several families. They lack basic services (water, gas, electricity). 100% of the families benefiting from CONIN’s programs do not own the dwellings they live in.
Households have very low-income family communication and little containment and stimulation; adult referents are illiterate or have not completed the primary cycle, a situation that worsens in the female population (69%). These characteristics are reflected in the poor assessment of education, which is clearly perceived in the high rates of repetition and dropout. About children, we could mention that they generally remain alone throughout the day, devoid of the care and affection of an adult. They have delays and disadvantages due to the lack of care and lack of control already suffered during the mother’s pregnancy, as well as malnutrition and malnutrition during the first years of life (product of low income, poor nutritional habits and prioritization of secondary needs)41.42.
The creation of these centres is based on the idea of addressing the social pathology that gives rise to malnutrition since it is of no use feeding a child if it is then reintegrated into the unfavourable environment to which it belongs. In prevention centres, the family and its environment are enhanced as the basis for the correct physical and intellectual development of the child, coupled with an adequate supply of nutrients, as demonstrated in UNICEF projects were working with the family in their own community reverses malnutrition and prevents malnutrition of siblings born later. Currently, these centres have spread in different provinces of Argentina, in Paraguay, and soon in Peru. In these centres, health prevention and promotion strategies are developed through different programs and services43.
• Nutritional Diagnosis: consists of evaluating all children from 0 to 5 years of age who enter the Center, through the weight-size ratio to determine the nutritional status of each child.
• Supplementary Food Assistance Program: According to the outcome of the nutritional diagnosis of each child and their respective family group, the type and quantity of foods to be included in a bag that is delivered weekly to families of the program with family basket commodities are determined. This program aims to assist families at high social risk, and who consequently have a nutritional deficit. Families who receive this food bag must pay a minimum amount of money, so as not to accustom people to free assistance; that only generates more leisure, more disability and therefore, more dependence. Likewise, those families who do not have that money also withdraw the bag in exchange for work in the centre.
• Nutritional Control: a weekly check is carried out for each child, to assess the effectiveness of the Complementary Food Assistance Program and to take the necessary measures in each case.
• Nutritional advice in the Culinary Arts Workshop and the Community Orchard Program: technical advice is provided to teachers of the aforementioned programs, as well as to mothers on what types of preparations can be made with food bag products.
• Breastfeeding Stimulation: This program assists a mother who breastfeeds their children. It aims to stimulate and recover breastfeeding.
Its objective is to know and improve the social problems of all the beneficiaries of the Center. The main functions are:
• Through home visits, it detects the needs of families in the area, inviting those with unmet basic needs to participate in the programs provided by the prevention centre.
• Family Ropero Program, which aims to meet the dress needs of the entire family group.
• Family Legalization and Documentation.
• Prevention and treatment of addictions.
It works with children from 0 to 5 years old, evaluating psychomotor development and the stimulation of cognitive and affective functions. This service is of paramount importance as it prepares the child for school, as these children lack the necessary stimulation in their homes.
Early stimulation service
Attend children from 0 to 3 years old. The main objective is to restore the mother-child bond, working with both so that the mother learns, through different tools, to achieve a psychomotor development suitable for the age of the child 44.45.
It works with children from 3 to 5 years old, intending to stimulate the area of language, which within psychomotor development is the one that is most at risk of delay.
Pediatrics and Health Education Service
This service includes various programs such as immunizations and oral-dental health.
Maternal and children’s garden
This program is attended by children from 0 to 5 years old, divided into three rooms: maternal (0 to 1 year); wanderers (2 to 3 years) and preschool (4 to 5 years).
This program assists children from 6 to 12 years old.
Literacy program for mothers and adolescents.
Through the Ministry of Education of the Province, a program is developed at the centre aimed at adult literacy.
Training in arts and crafts for mothers and adolescents
The goal of these workshops is to provide a practical and fast work exit. It should be noted that these workshops last for one year with an hourly load of 90 hours and are provided to persons attending a degree endorsed by the Ministry of Education of the Province.
Community orchard programme
Through an agreement with the Billing Mendoza Institute, professionals who are experts in the topic of natural family planning, advise all mothers who come to the centre.
Recreation and sports program for teens
Prevent the socio-bio-cultural problems of marginal adolescents by promoting sports and recreational activities, limiting the leisure time caused in many of them by antisocial behaviours such as crime, prostitution, violence, drug dependence, alcoholism, etc.
With the implementation of these programs and services, this malnutrition prevention centre has been called a human promotion centre, since each activity aims to provide people with solid tools, which allow them to fight for their well-being with greater opportunities46.
Evidence of the effectiveness and effectiveness of the project
There are 2 studies, one that evaluates the activity of the recovery centre and another study showing a socioeconomic assessment of the prevention centre.
1. In October 2003, a retrospective study was conducted with 75 children admitted to the recovery centre. The following results were obtained from the study: average age at income 1 year and 3 months, days of average internment: 35 days, 56% of children entered with primary malnutrition, 44% with secondary malnutrition (malabsorption syndrome, neurological diseases, genetic syndromes, congenital heart disease, gastrointestinal alterations, renal alterations). The percentage variations of the variables studied since discharge were: Denver/age test, 30.5% improvement, weight: 31.3% increase, size: 16.7% increase47.
2. In 1997 Lledó exhibited in the Master’s Degree in Project Assessment Sciences, Finance and Investments of the University of York, England, his research work, where a “Socioeconomic Evaluation of the CONIN Child Malnutrition Prevention Center” is carried out. The evaluation of the prevention centre (CP) was carried out taking into account the costs and benefits from a social point of view, taking into account that child malnutrition correlates with different social indicators, such as low educational level of parents, precarious housing, unfavourable environmental conditions, health problems, etc. All of these factors are related to extreme poverty, which is why the unmet basic needs (NBI) were used as an indicator of these factors. With this research, several benefits could be identified, which are interrelated to each other, with the effects assessed before and after intervention in THE CONIN CP.
Increased food consumption
To analyze the results of the child’s nutritional changes by attending the CP, a nutritional survey of the children was conducted when they entered CONIN (situation without intervention) and compared it to the food situation of these children after attending CONIN 8 months (the situation with intervention). The results indicate that in the non-intervention situation, these children consume 21,555 calories per month and with intervention 31,800 calories per month. Comparing these values with WHO recommendations of 43,002 calories per month show that 74% of these recommendations are reached before the intervention, and 74% of these recommendations are reached before the intervention. The increase in the number of calories consumed per child is mainly due to the food assistance program where 2 boxes of milk per month are given to each child (on average), and one food bag per month to each family of these children; and the nutrition education programs that mothers receive. This benefit also extends to pregnant mothers who attend CP.
Assessment of a child’s preschool stimulation
Much of the delays in children’s psychosocial development are due to the inadequacy of sensory and emotional stimuli required in quality, quantity and opportunity. The benefit of increased preschool stimulation is expressed in the child’s increased learning capacity and social development. Children in extreme poverty at risk of malnutrition (situation without intervention) receive very little preschool stimulation. At CP CONIN, children receive 18 hours a month of preschool stimulation. To calculate this benefit, it was compared to the cost of sending these children to a private daycare centre where they receive 18 hours of monthly care, recognizing the limitation that private daycare is not equal to a CP, since in the CP in addition to preschool stimulation, the child receives food and social care. By receiving more stimulation from the child, the child can achieve better preparation to meet the demands of basic school and, as a result, greater productivity in his or her adult life.
Child morbidity benefits
Preventing malnutrition in CP leads to resource savings by reducing the number of children born underweight, and inpatient hospitals and outpatient consultations for diseases.
Impact on a child’s schooling
It is noted that in children assisted in CP, dropout and school repetition rates decrease, and the child reaches schooling levels, implying higher expected incomes. Decreased dropout involves a higher social cost, both direct and indirect.
The higher social cost is due to the greater amount of resources that must be allocated to those who stay longer within the school system because they have not defected (greater number of teachers, greater use of equipment and infrastructure, greater use of school and didactic material, etc.). The indirect social cost is generated by the fact that the student is delayed from the labour market, so there is future income that he no longer receives.
Mothers’ higher education benefits
At the CP, mothers raise their level of education and training with workshop activities, educational exhibitions and the adult literacy program. This increase in the education level of the mother is reflected in higher future productivity, which represents a social benefit.
It should be noted that in addition to the socio-economic benefits assessed number of unevaluated benefits should be taken into account, such as decreased infant mortality, the effect of increased schooling of children whose parents attend the CP, the impact of knowledge dispersion since mothers and children attending the CP can pass on acquired education to their families and other community members.
Discussion: intervention strategies
The social problem that gives rise to child malnutrition has numerous conditions that must be taken into account when considering solutions. These conditions have been identified by CONIN, being its strategy of the intervention of great health impact since it enhances the family and its environment as the basis of the correct physical and intellectual development of the child, together with an adequate supply of nutrients, which allow the child to develop its genetic potential.
The humanitarian response to hunger needs to be rapid, well-coordinated and based on strong epidemiological evidence 49. Nutritional intervention programmes have evolved by shifting their primary emphasis from protein deficiency control, energy deficiency, and now to micronutrient deficiencies 50.51. The most commonly used strategies for the control of micronutrient deficiency 52.53 are supplementation and strengthening because they are profitable and to some degree, easier access to the population 54.55. However, little emphasis has been placed on comprehensive nutritional intervention programmes taking into account social and psychoactive factors in poverty and underdevelopment 56conditions, perhaps because of the complexity of a multifactorial intervention that also makes it difficult to assess.
There is ample evidence that the potential effect of nutritional interventions on the prevention of child morbidity under poverty and underdevelopment57 is estimated, however, Latin America has weight gain trends in some regions, especially in urban areas, indicating dietary changes, with excess fats and carbohydrates to the detriment of grains, fruits and vegetables. Hence, interventions in education and the way of life required to optimize nutrition and health are a current imperative 58. This objective is rooted in CONIN’s strategy, being one of the pillars on which it supports its work.
The program developed by CONIN in Latin America, constitutes a unique and comprehensive experience of intervention in community nutrition, acting as a tool to promote health 59, which can be developed on other continents, adapting community intervention according to the predominant problems at each latitude. In this sense, the Spanish Society of Community Nutrition (SENC) aims to promote interregional and regional cooperation in the field of research, teaching and development of strategies for strengthening aspects related to nutrition and health.
The comprehensive care of the malnourished child by specialized professionals, the training and incorporation of the mother into the daily care of her child, is a valid strategy that generates a significant recovery of the evolutionary degree of psychomotor, weight and size of patients.
In the evaluation of the prevention centre project, several benefits have been identified that show a positive health impact on the population of its area of influence. Still, some benefits have not been valued, such as cost savings because serious diseases detected in the CP are reported to the hospital immediately after detection. This means a lower risk of infecting others, lower treatment costs, avoiding irreparable physical harm, lowering the risk of infant mortality, etc. Therefore, it is advisable to delve into the study of these health-related benefits. International cooperation, in the objective of eradicating child malnutrition, is not only feasible but also necessary and priority.
- Alvear J, Vial M, Artaza C: Growth after severe early malnutrition. Rev Chil Pediatr 1991; 62: 242-47.
- McLaren DS: Protein Energy Malnutrition (PEM). In: McLaren DS, Burman D (eds). Textbook of Pediatric Nutrition. Edinburgh, London, New Cork: Churchill Livingstone, 1976. p. 105-17.
- Keating D, Hertzman C, eds: Developmental health and the wealth of nations: social, biological and education dynamics. The Guilford Press, New York, 1999.
- Roncagliolo M, Garrido M, Walter T, Peirano P, Lozoff B: Evidence of altered central nervous system development in infants with iron deficiency anemia at 6 mo: delayed maturation of auditory brainstem responses. Am J Clin Nutr 1998; 68: 683-90.
- Lozoff B, Jiménez E, Hagen J, Mollen E, Wolf AW: Poorer behavioral and developmental outcome more than 10 years after treatment for iron deficiency in infancy. Pediatrics 2000; 105: E51.