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close this bookFood and Nutrition Bulletin Volume 16, Number 4, 1995 (UNU, 1995, 135 pages)
close this folderSpecial issue on care and nutrition of the young child
View the documentUNICEF-Cornell colloquium on care and nutrition of the young child - Introduction
View the documentUNICEF-Cornell colloquium on care and nutrition of the young child - Overview UNICEF-Cornell colloquium on care and nutrition of the young child - Introduction
View the documentUNICEF-Cornell colloquium on care and nutrition of the young child - Planning UNICEF - Cornell colloquium on care and nutrition of the young child - Planning
View the documentEthics and child nutrition

UNICEF-Cornell colloquium on care and nutrition of the young child - Introduction

Cutberto Garza

The papers contained in this special issue were presented initially at a Colloquium on Care and Nutrition of the Young Child, sponsored by UNICEF and Cornell University's Division of Nutritional Sciences, and held at Aurora, New York, USA, in October 1994. The planning of the Colloquium grew out of UNICEF's recognition of the need for a systematic review and integration of available knowledge concerning the question of how variations in the quality of care received by infants and young children may either enhance or compromise their nutritional status, growth, and behavioural development. Considered equally important was the analysis of various factors in the family and of the larger ecological setting that may affect caregivers' ability to provide good care, as well as the availability of resources essential for it. It was hoped, also, that a review of this knowledge base would provide guidelines for proposed strategies that might be employed in a variety of settings for protecting, supporting, and promoting good child care in the interest of improved nutrition and development. The articles that follow include most of the papers presented at the Colloquium.

The first two papers provide an overview of the relationship between care and nutrition, and a summary of the planning process leading to the Colloquium, including the conceptual framework and rationale for selecting the topical issues addressed. The third paper discusses ethical issues related to nutrition policies in the context of UNICEF's Nutrition Strategy.

The next six articles review the research literature dealing with various aspects of early child care that may have an impact on nutrition, growth, and behavioural development: breastfeeding as care, sustained breastfeeding, complementary feeding practices, the role of appetite, nutritional care during illness, and the role of psychosocial care. Some factors that may significantly influence the quality of care young children receive are discussed in the final four papers: cultural setting of care and caregiver roles, health and nutrition status of caregiver, modernization and urbanization, and coping with emergency or refugee situations.

Suggested strategies for protecting and enhancing the quality of various aspects of care are touched upon in many of the papers in this issue. In addition, at the close of the Colloquium, several work groups drafted preliminary recommendations for research aimed at improving care practices and for action strategies that might be employed to improve child care and nutrition at the policy and planning levels. These recommendations have been made available to UNICEF for further consideration and review.

On behalf of the editorial committee, I wish to thank UNICEF for its sponsorship of this activity, which underscores the importance of creating new knowledge and scholarship in determining courses of action. It also served as a valuable chance to bring biologists, social scientists, and practitioners together to examine a topic that goes beyond child survival. I also wish to acknowledge the valuable help of the other two members of the editorial committee, Henry Ricciuti and Michael Latham.

UNICEF-Cornell colloquium on care and nutrition of the young child - Overview UNICEF-Cornell colloquium on care and nutrition of the young child - Introduction

Cutberto Garza

The papers contained in this special issue were presented initially at a Colloquium on Care and Nutrition of the Young Child, sponsored by UNICEF and Cornell University's Division of Nutritional Sciences, and held at Aurora, New York, USA, in October 1994. The planning of the Colloquium grew out of UNICEF's recognition of the need for a systematic review and integration of available knowledge concerning the question of how variations in the quality of care received by infants and young children may either enhance or compromise their nutritional status, growth, and behavioural development. Considered equally important was the analysis of various factors in the family and of the larger ecological setting that may affect caregivers' ability to provide good care, as well as the availability of resources essential for it. It was hoped, also, that a review of this knowledge base would provide guidelines for proposed strategies that might be employed in a variety of settings for protecting, supporting, and promoting good child care in the interest of improved nutrition and development. The articles that follow include most of the papers presented at the Colloquium.

The first two papers provide an overview of the relationship between care and nutrition, and a summary of the planning process leading to the Colloquium, including the conceptual framework and rationale for selecting the topical issues addressed. The third paper discusses ethical issues related to nutrition policies in the context of UNICEF's Nutrition Strategy.

The next six articles review the research literature dealing with various aspects of early child care that may have an impact on nutrition, growth, and behavioural development: breastfeeding as care, sustained breastfeeding, complementary feeding practices, the role of appetite, nutritional care during illness, and the role of psychosocial care. Some factors that may significantly influence the quality of care young children receive are discussed in the final four papers: cultural setting of care and caregiver roles, health and nutrition status of caregiver, modernization and urbanization, and coping with emergency or refugee situations.

Suggested strategies for protecting and enhancing the quality of various aspects of care are touched upon in many of the papers in this issue. In addition, at the close of the Colloquium, several work groups drafted preliminary recommendations for research aimed at improving care practices and for action strategies that might be employed to improve child care and nutrition at the policy and planning levels. These recommendations have been made available to UNICEF for further consideration and review.

On behalf of the editorial committee, I wish to thank UNICEF for its sponsorship of this activity, which underscores the importance of creating new knowledge and scholarship in determining courses of action. It also served as a valuable chance to bring biologists, social scientists, and practitioners together to examine a topic that goes beyond child survival. I also wish to acknowledge the valuable help of the other two members of the editorial committee, Henry Ricciuti and Michael Latham.

UNICEF-Cornell colloquium on care and nutrition of the young child - Planning UNICEF - Cornell colloquium on care and nutrition of the young child - Planning

Usha Ramakrishnan

Abstract

The need to develop appropriate knowledge-based strategies to promote better care was the basis for the UNICEF-Cornell University Colloquium on care and nutrition of the young child. The first step was to develop a conceptual model that described the various factors that influenced the quality of care and the pathways through which care influenced the nutrition status of young children below three years of age. The direct care-related behaviours included breastfeeding, complementation, feeding during illness, health related behaviours, and psychosocial care. Several underlying factors at the household, community, and national level and the interactive process of care were also considered. The resource constraints and trends were child characteristics; caregiver factors, including time availability; psychological, health, and nutrition status; organizational resources; and modernization and urbanization. The triple-A process of assessment, analysis, and action was followed to identify, understand, and prioritize the key areas while planning for the Colloquium. Besides the focus and theme papers, case-studies from developing countries and working group sessions were also included.

Introduction

UNICEF nutrition strategy recognizes care as an important determinant of nutrition status as part of its conceptual framework [1]. Care was first identified as a missing ingredient in the Joint Nutrition Support Program in Iringa, Tanzania, and has since been articulated in positive deviance studies in various developing countries [2-4]. These studies have demonstrated that in spite of adverse conditions, e.g., poverty, food insecurity, and limited health care, enhanced caregiving could optimize existing resources to promote good health and nutrition in young children. The concept of care is broad and has different meanings across disciplines.

The need to identify current knowledge in this area and consequently develop appropriate strategies to promote good care has been recognized. A detailed review of the literature analysing the role of care in nutrition was prepared as a theme paper for the International Conference on Nutrition held in Rome in 1992 [5]. A draft strategy on care and nutrition has been evolving primarily through the efforts of UNICEF [6]. An understanding of the dynamics of caregiving in different settings is needed to identify strategies to promote better care as well as improve food security and health. This formed the basis of the planning for the UNICEF-Cornell University Colloquium on care and nutrition.

Planning

Cornell conceptual model for care and nutrition

A conceptual model describing the various factors that influence quality of care and how care itself influences nutrition status was developed at Cornell University (fig. 1). Since care is such a broad area, this framework focused specifically on the care of children below the age of three years and its implication for improving nutrition status. It evolved from the UNICEF nutrition strategy [1], which defines household food security, care of women and children, and access to health services, along with a healthy environment, as the necessary ingredients to promote good nutrition. Adequate dietary intake and health status are the immediate determinants of good nutrition, but caregiving ultimately determines the delivery of adequate food and health to the child. Although closely linked to household food security, the actual amount of food ingested by the young child is determined by care-related feeding behaviours such as breastfeeding, complementation, food preparation, and overseeing the progression of the child from complete dependence to partaking of adult family food. Similarly, care-related behaviours determine how available health services, for both preventive and curative purposes, are utilized to optimize child health and thereby influence nutrition. Finally, factors such as affection, psychosocial stimulation, emotional stability, predictability, and patterning are important to the overall development of the child [7, 8].

In addition to these direct care-related behaviours, it is important to recognize that care is a highly interactive process between child and caregiver, with inputs by and rewards for both. It is vital to regard care in the context of a dyed while planning strategies. Although mothers are generally assumed to be the primary caregivers, it should not be overlooked that in many societies caregiving is shared by siblings, other relatives, fathers, neighbours, and caregivers in day-care centres and family day-care homes. Planning strategies must consider several factors relating to both the caregiver and child that determine caregiving behaviour. These relate to the time demands, cultural attitudes, beliefs, and knowledge of the caregiver as well as several characteristics of the child including gender, age, birth order, appetite, and level of intellectual and motor development. The immediate environment of this interactive behaviour is in turn influenced by various other factors operating at the household, community, and national level. A planning document [9] describing this framework, combined with an update of the literature and suggestions for the workshop, was presented by Cornell University to UNICEF in December 1993.



FIG. 1. Conceptual framework for care and nutrition of the young child

London meeting

A meeting to finalize the plans for the UNICEF-Cornell workshop on care and nutrition was held at the Institute of Child Health, London University on 6-7 January 1994. This meeting was attended by Drs. U. Jonsson, M. Kyenkya-Isabirye, D. Alnwick, and J. Csete from UNICEF (Nutrition Cluster, New York); M. C. Latham, H. Ricciuti, and U. Ramakrishnan from Cornell University; T. Greiner (Uppsala University-SIDA, Sweden); P. Engle (California Polytechnic University, San Luis Obispo, California, USA); and A. Tompkins and R. Longhurst from the Institute of Child Health, London University. Most of the above comprised the Organizing Committee for the Colloquium.

At the outset it was recognized that care is a very broad area, and that although other areas, such as education, women's development, and social welfare, are important, the focus of the workshop would be limited to nutrition-related aspects. It was also agreed by the group that present efforts would be limited to children under three years of age in developing countries with large numbers of malnourished children (mainly in Africa and Asia). The importance of care of older children and women was recognized but not included in order to limit the topic. The objectives for the workshop were defined to summarize present knowledge of inadequate care and nutrition as well as to identify gaps in knowledge. Our understanding of care and nutrition can be classified as resolved issues, unresolved issues, need for further research, and application.

The triple-A process of assessment, analysis, and action [10] was followed to help identify, understand, and prioritize key areas to be included in the conference. The first step of assessment was identifying issues specifically related to inadequate care practices influencing nutrition. Based on our present understanding and conceptual framework of care and nutrition, a list of issues (table 1) was identified.

It was clear that all the topics in the list could not be addressed in a single workshop and that simplification to narrow down the key issues was required. This was done systematically for each category, and the process is summarized in the following section. The topics selected for the final list are highlighted in bold type in the table, and the areas of concern to be addressed for the colloquium are described below.

TABLE 1. List of care practices that might influence the nutrition status of the young child

Feeding breastfeeding Breast feeding
Exclusive breastfeeding
Sustained breastfeeding
Cessation of breastfeeding
complementation Timing/quantity
  Replacement of breastmilk
Energy density/nutrient quality
Feeding frequency (in 24 hours)
Palatability
Feeding style
Appetite
Contamination/safety
Prevention of illness Hygiene
personal bathing, handwashing
household water, sanitation, domestic animals, food
preparation
Prevention of accidents
Utilization of health service
Traditional practices
Care during illness Hausehold
Feeding (at home and in service settings)
Health-seeking behaviour
Psychosocial care Care giver involvement and affection/love
Sensitivity and regularity of response
Mutually rewarding reciprocal interaction
Providing opportunities for play, exploration, and learning
Socialization and mom training
Safety and stability of the home environment Continuity and number of caregivers over time
Crowding
Protection from cold

Assessment

Feeding

Breastfeeding

Breastfeeding is the only activity that satisfies the needs of food, health, and care at the same time. Although breastfeeding was acknowledged as an extremely important component of care, it was agreed that issues such as breastfeeding initiation, exclusive breastfeeding, and so on would not be addressed, since they have already been considered in detail by the breastfeeding promotion efforts of UNICEF. Yet the relevance of the overlap between breastfeeding and care (nearly 85%) was nominated as a special topic for the workshop. The need to address issues beyond the Innocenti Declaration was raised, especially within the protect, support, and promote framework. Evaluation of present strategies used to protect, support, and promote breastfeeding, combined with the need to balance community versus health care resources, was to be included in this general paper.

Although originally disregarded, the issue of sustained breastfeeding was raised in the discussions on complementary feeding. Two areas of concern warranted special attention: the dangers of promoting exclusive breastfeeding while simultaneously supporting sustained breastfeeding, and the benefits of sustained breastfeeding in the second year of life [11,12] within the nutrition and care perspective.

Complementation

Introducing foods in addition to breast milk signals the beginning of one of the most vulnerable phases in the life of young children in developing countries. This period may begin from as early as 2 months to as late as 18 months of age in different cultures. Decisions related to when to introduce other supplementary foods, choice of food, and quantity and frequency of feeding are inherently linked with caregiving practices in different cultures. Complementary feeding was regarded as a high-priority area where inadequate care practices would affect the nutrition status of the child, and three major themes emerged.

1. Timing of complementation and replacement of breastmilk. There is considerable debate about the timing of complementary foods, especially their effect on children's eating behaviour and growth [13, 14]. It was agreed that the transition from exclusive breastfeeding to introducing appropriate amounts of other foods merits high priority. Clarification of how much to replace breastmilk with other foods is intrinsic to the discussion of timing and quantity of complementary foods. It is important to understand the factors influencing total energy intake and the relative contributions from breastmilk and complementary foods when forming strategies that influence care.

2. Nutrient density and frequent feeding. Infrequent feeding and low nutrient and energy density of complementary foods have been recognized as major problems contributing to malnutrition [15,16]. However, although caloric and nutrient density of complementary foods and feeding frequency can be regarded as two separate topics, they need to be addressed together. When the intake of bulky foods is coupled with infrequent feeding, it is difficult for the young child to obtain adequate nutrients. Limitations to frequent feeding could be addressed by promoting foods with higher nutrient density. Although the relationship between eating frequency and caloric density seems obvious, few studies have documented this under home conditions [17]. Current scientific knowledge about the relationship between feeding frequency and nutrient density (not only calories but also micronutrients such as vitamin A and iron) should be used to plan strategies.

3. Appetite and feeding style. Palatability of foods, feeding style, and appetite were identified as extremely important and interrelated factors where inadequate care determines the actual food intake of the child [18, 19].

4. Contamination. This topic was included in the broader topic relating to hygiene.

Prevention of illness

Hygiene was recognized as the most important aspect of inadequate care to be included in the Colloquium. Although utilization of health services was also considered important, it was excluded as it is being addressed by other groups. Hygiene operates at the personal, household, and community levels. Household hygiene was given particular priority and included issues related to water and sanitation, i.e., disposal of faeces, especially among young children, quality of play area, relevance of handwashing, contamination of weaning foods, and the presence of domestic animals in living areas.

Care during illness

Although health-seeking behaviours and the role of health professionals and traditional practices were recognized as important areas, only the nutritional management of illnesses was to be addressed at this meeting. The efforts of the Sick Child Initiative promoted by the health section of UNICEF were mentioned as well as the need to integrate the efforts of health and nutrition groups. Feeding during illness was assigned high priority for this Colloquium [20]. In particular, nutritional management of symptoms such as pain, fever, ulcers, and breathlessness was addressed. The increasing privatization of primary health care and the need to establish standards for care were also regarded as important. The role of the service settings such as clinics and hospitals in determining the care that a child receives during illness, especially in relation to feeding, warranted special attention. Finally, the evaluation of public health messages, such as the promotion of oral rehydration salts in the management of diarrhoea, can also be addressed when considering care during illness within the protect, support, and promote framework.

Psychosocial care

Research literature in developmental psychology and child development allows us to identify several characteristics of early child care or child rearing that are positively associated with socio-emotional, intellectual, and motor development in young children. These include maternal involvement and affection, sensitivity and regularity in responding to the child's needs, engaging in mutually rewarding interactions with the child, and providing opportunities for play, exploration, and learning [7, 21]. Given the focus of the Colloquium on linkages between inadequate care and nutrition status, it is important to note that these same characteristics also tend to be positively associated with nutritional care, and thus with positive nutritional and growth outcomes. Although these four dimensions of good care tend to be interrelated, there was some discussion of the possibility that the fourth characteristic (providing opportunities for play, exploration, and learning) should be given separate consideration, since it may be more closely linked to cognitive development.

Issues related to socialization and discipline were assigned lower priority, since considerably less is known about their impact on early behavioural development, and the issues are highly culture specific. However, this area may be addressed by examining the role of moral training in different cultures, as it is extremely important in determining the amount of food that the child may receive. Also, socialization and discipline practices that are clearly neglectful or abusive would be considered instances of poor care according to the four characteristics already mentioned.

Safety and stability of the home environment

The nature of the physical environment in the home was regarded as important, especially in view of the fact that care is multidimensional and should not be restricted to feeding and psychosocial care. Factors related to the stability and safety of the child's environment, including the prevention of accidents and the availability and consistency of caregivers over time, cannot be ignored. However, limitations in time and budget resulted in the assignment of a lower priority for this topic.

Analysis

The next stage was analysis, i.e., to understand the underlying and basic causes that contribute to observed inadequacies in care leading to impaired nutrition status. This stage can be closely linked to action, where strategies evolve to deal with care and nutrition. Underlying causes were identified for the specific examples outlined earlier to determine common themes. The following generic factors influencing the triple-A cycle [10] were used to aid this process: perception and understanding, effective demand, capabilities, and resources. The common underlying and basic factors related to resource constraints at various levels, as well as trends based on the conceptual model, were child characteristics, caregiver factors, organizational resources, and the impact of modernization, urbanization, and societies in change.

Child characteristics

Child care is a highly interactive process in which the caregiver and the child operate as a dyed. Conventional approaches to care have tended to concentrate on the caregiver. There is increasing evidence that several child characteristics elicit different responses from different caregivers, for example, temperament (irritability, crying), birth order, gender, the stage of motor and intellectual development (activity patterns, attention-seeking behaviours), and appetite. Infants differ in adaptability, activity level, irritability, exploratory behaviour, and response to new situations. A child who is more active and explores more might increase his or her ability to locate caregivers and evoke caregiving, in contrast to the severely malnourished child who is listless, passive, and apathetic about his or her surroundings. The child's development stage also plays a key role in determining the nature of care-related behaviours elicited and consequently directly influences both the food intake and the health status of the young child. For example, the degree of vocalization can determine the ability of the child to demand food and consequently the amount of food he or she will receive. Similarly, the level of motor development is closely linked to exploratory behaviour and may influence child characteristics such as assertiveness and demand for attention. Very little is known about mechanisms that characterize caregiver-child behaviour in developing and responding to cues for hunger, satiety, and food preferences during these vulnerable stages. Other special groups include children with physical handicaps or mental disorders and those subject to social discrimination because of their gender, parity, twin status, uncertain parentage, or membership in socially disadvantaged groups. Refugee children are a growing group whose needs are unique. Children who are of high birth order or who are female have been reported to receive less attention in parts of South Asia.

Caregiver characteristics

The importance of the quality of the home environment and the mother-infant interaction in the psychological development of the young child has been widely studied and recognized. These same factors could influence child growth through care. Inadequate child care in developing countries is often assumed to be due to mothers' limited knowledge. Although this may be partly true, the competing demands on poor mothers' time that prevent appropriate child care need to be recognized. The interaction between the time, knowledge, and income constraints of the caregiver needs high priority in planning strategies to improve child growth and development. The following areas were recognized as high priority for the Colloquium.

Caregiver time

Studies conducted throughout the developing world reveal that women commonly work longer hours than men and that women do more than their fair share of work in agricultural activities, as well as in household chores [22, 23]. They are largely responsible for maintaining household continuity through reproduction and nurturing children, and perform most of the key and energy-demanding tasks for the households. Heavy demands on women's time due to income-producing and home production activities limit the time available for child care. Yet social science research reveals that mothers resort to various compensatory mechanisms that might buffer the negative effects of time constraints [24-27]. An understanding of these mechanisms is useful in planning strategies to promote better child care. In particular, the role of factors such as family structure, control of household income, the time required for certain basic home production activities (food processing and preparation, obtaining fuel and water), and participation in and implementation of four key child survival activities (breastfeeding, immunization, growth monitoring, and oral rehydration) needs to be evaluated.

Psychological and emotional state of the caregiver

Studies have shown that mothers of severely malnourished children are often those with low self-esteem, low confidence, and less education. In contrast, positive deviance studies have shown that mothers of children who grow well despite adverse socio-economic constraints are highly motivated and spend more time on quality care [3, 4]. A review of strategies that have been used to improve maternal self-esteem and confidence in both developing and developed countries is recommended. Consideration should be given to various maternal or caregiver personality characteristics, attitudes, and beliefs that may have a positive or negative influence on quality of child care. These might include a sense of empowerment or personal efficacy; self-esteem; knowledge, attitudes, and beliefs supportive of good child-care practices; and positive attitudes towards health care and education. Negative influences might result from maternal depression, passivity, low self-esteem, lack of basic knowledge regarding good care, and attitudes and beliefs likely to lead to poor child-care practices.

Health and nutrition status of the caregiver

The health and nutrition status of the primary caregiver, often the mother, was recognized as important in determining the quality of care that the child receives. High priority was assigned to reviewing the evidence demonstrating how the overall health and nutrition status of the mother or caregiver affects the amount and quality of care, specifically the impact of competing risks of both reproductive and productive demands on the woman of child-bearing age in most developing countries. Practical suggestions for action were also emphasized.

Organizational resources

Organizational resources are available at the community, district, and national levels that may be utilized to improve the quality of care. In particular, the role of out-of-home care, including informal child-care arrangements in different settings and cultures; the role of the health professional; and, finally, the role of both government and non-government organizations from the community to the national level need to be considered. In most societies, especially in developing countries, child care is not the sole responsibility of a single caregiver, but is shared by alternative caregivers. It is important to understand the role of alternative caregivers, especially fathers. Specific concerns included identification of the alternative caregivers and strategies available to make them more effective, evaluation of the proportion of time the child spends with the mother or other primary caregiver and the alternative caregiver, as well as time spent alone, and how these influence programmes aimed at improving nutrition and care. Also recommended was an evaluation of the different types of out-of-home care common in various settings, including both formal and informal arrangements, particularly arrangements having potential or actual nutritional benefits.

Modernization and urbanization

Trends in society such as modernization, urbanization, and westernization proceed rapidly. Their impact on traditional structures and patterns needs to be examined, particularly those affecting child-rearing practices.

Action

There was considerable discussion of how to deal with the issues described above. The possibility of addressing these issues with the topics identified in the assessment phase was considered. Different options were considered in relation to this outcome. It was decided that although suggestions for action, namely what to do, were regarded as a major outcome of this workshop, aspects related to implementation, such as empowerment and communication, i.e., how to do it, would not be addressed. The need to include developing country perspectives in care and nutrition was also acknowledged. It was finally decided that the underlying issues affecting the quality of care would be addressed as individual theme papers in the broad context of care and nutrition. Similar consideration of these issues was also to be included in the earlier-described focus papers. The importance of using the protect, support, and promote framework for all topics was stressed, especially in identifying good caring practices that need to be protected, as well as the threats to these practices as a result of modernization and urbanization, and methods to develop culture-specific indicators.

References

1. UNICEF. Strategy for improved nutrition of children and women in developing countries. New York: UNICEF, 1990.

2. UNICEF/WHO. Joint nutrition support programme in Iringa, Tanzania, 1983-88. Evaluation report. New York: UNICEF, 1988.

3. Zeitlin MF. Child care and nutrition: the findings from positive deviance research. Final report to UNICEF. New York: UNICEF, 1993.

4. Engle PL, Lamontagne JF, Zeitlin MF. Caring capacity within the household and nutritional status: an observational study of caring behaviors, Managua, Nicaragua. Revised final report. New York: UNICEF, 1992.

5. Engle PL. Care and child nutrition. Theme paper for the International Conference on Nutrition. New York: UNICEF, 1992.

6. Longhurst R. A strategy paper for nutrition and care. New York: UNICEF, 1993.

7. Super CM, Herrera MG, Mora JO. Long-term effects of food supplementation and psychological intervention on the physical growth of Colombian infants at risk of malnutrition. Child Dev 1990;61:29-49.

8. Grantham SM, Powell CA, Walker SA, Himes JH. Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaica study. Lancet 1991;338:1-5.

9. Ramakrishnan U. Preliminary planning for the Cornell-UNICEF workshop on care and nutrition. New York: UNICEF, 1993.

10. Jonsson U. Ethics and child nutrition. Food Nutr Bull 1995;15:293-8.

11. Victora CG, Vaughn JP, Martines JC, Barcelos LB. Is prolonged breast-feeding associated with malnutrition? Am J Clin Nutr 1984;39:307-14.

12. Taren D, Chen J. A positive association between extended breast-feeding and nutritional status in rural Hubei Province, People's Republic of China. Am J Clin Nutr 1993;58:862-7.

13. Dewey KG, Peerson JM, Heinig MJ, Nommsen LA, Lonnerdale B. Lopez-De-Romana G. de Kanashiro HC, Black RE, Brown KH. Growth patterns of breastfed infants in affluent (United States) and poor (Peru) communities: implications for timing of complementary feeding. Am J Clin Nutr 1992;56: 1012-8.

14. Armstrong H. Discussion paper: breastfeed first or give soft foods first? A review of current recommendations. New York: UNICEF, 1993.

15. Jellife EFP, Jellife DB. Improving nutritional dietary density and nutrient bioavailability for young children. Less appreciated considerations. J Trop Pediatr 1990; 36:210-2.

16. Brown KH. The importance of dietary quality versus quantity for weanlings in less developed countries: a framework for discussion. Food Nutr Bull 1991;13:86-93.

17. Garcia SE, Kaiser LL, Dewey KG. The relationship of eating frequency and caloric density to energy intake among rural Mexican preschool children. Eur J Clin Nutr 1990;44:381-7.

18. Dettwyler KA. Styles of infant feeding: parental/caretaker control of food consumption in young children. Am Anthropologist 1989,91:696-703.

19. Bentley ME, Dettwyler KA, Caulfield LE. Anorexia del niños y su manejo en paises en vies de desarrollo: revisión y recomendaciones. In: O'Donnell A, Torun B. Caballero B. Lara E, Bengoa JM, eds. La alimentación del niños menor seis años en América Latina: bases pare el desarrollo de guias de alimentación. Washington, DC: ILSI/OPS, in press.

20. Huffman SL, Lopez-De-Romana G. Madrid S. Brown KH, Bentley M, Black RE. Do child feeding practices change due to diarrhoea in the central Peruvian highlands? J Diarrhoeal Dis Res 1991;9:295-300.

21. Ricciuti HN. Adverse environmental and nutritional influences on mental development: a perspective. J Am Dietet Assoc 1981;79:115-9.

22. Huffman SL. Women's activities and impacts on child nutrition. In: Gittinger JP, Leslie J, Hoisington C, eds. Food policy: integrating supply, distribution and consumption. Baltimore and London: The Johns Hopkins University Press, 1987:371-84.

23. Leslie J. Women's work and child nutrition in the third world. World Dev 1988;16:1341-62.

24. Wandel M, Holmboe-Ottesen G. Women's work and agriculture and child nutrition in Tanzania. J Trop Pediatr 1992;38:252-5.

25. Panter-Brick C. Lactation, birth spacing and maternal workloads among two castes in rural Nepal. J Biosoc Sci 1991;23:137-54.

26. Panter-Brick C. Motherhood and subsistence work: the Tamang of rural Nepal. Hum Ecol 1989;17:205-28.

27. Khandker SK. Women's time allocation and household nonmarket production in rural Bangladesh. J Dev Areas 1987;22:85-101.

Ethics and child nutrition

Urban Jonsson

Abstract

All problems in society have a scientific and an ethical aspect. Science tells us what can be done, whereas ethics tells us what should be, ought to be, or must be done. Actions that both should be done and can be done are do-able actions. Science is advanced mostly by observation and logical deduction or induction. Ethics, in contrast, is advanced by consensus through reflection, dialogue, enquiry, and sometimes struggle. Adequate care of children and women has only recently been fully recognized as a human right. The UNICEF triple-A approach of assessment, analysis, and action is designed to lead to more effective and better-focused actions for ensuring adequate care of underprivileged women and children. A rights-based approach, combining goal-based and duty-based ethical theories, is also proposed. Combined with the triple-A process, this provides a holistic response for addressing nutrition problems. The international goals of the World Summit for Children represent moral minima, accepted and supported by all major religions and political ideologies.

Science and ethics

Both science and ethics pursue unachievable goals. Science seeks the truth and ethics seeks the ideal society. In both cases it is fully rational to pursue these unachievable goals [1]. It is a scientific fact that iodine deficiency disorders (IDD) can be reduced by universal ionization of salt; it is an ethical choice of a government to decide to do so. It is a scientific fact that aggressive marketing of breastmilk substitutes contributes to the malnutrition of young children; it is an ethical choice of a government to decide to stop such a practice.

Theory and practice

Both science and ethics are driven and influenced by theory and practice. In science "we find what we look for" [2]. We all carry preconceived ideas about the nature of a problem. For years nutrition scientists thought that lack of protein was the primary cause of protein-energy malnutrition (PEM). They designed sophisticated instruments and methods to measure protein deficiency. They found what they were looking for. Today we know that in most cases, PEM is caused by a combination of inadequate dietary intake and the adverse effects of infection. Not until recently have nutrition scientists started to look for the prevalence and duration of exclusive breastfeeding.

Theory and practice of a scientific approach to nutrition problems

UNICEF's nutrition strategy [3] promotes an explicit theory or conceptual framework for the immediate, underlying, and basic causes of malnutrition in young children. This strategy also outlines an operational framework for how nutrition can be improved in practice (the triple-A approach).

The conceptual framework

The nutrition status of an individual, including any of the four major forms of malnutrition (PEM, IDD, vitamin A deficiency, and iron deficiency anaemia), is an outcome of complex biological and social processes, as summarized in the conceptual framework of figure 1.

Immediate causes

Inadequate dietary intake and disease are the immediate causes or determinants of malnutrition. The inadequacy may include total energy, protein, vitamins, or minerals. Inadequate dietary intake may increase the susceptibility to and severity of infection; conversely, many infectious diseases reduce dietary intake and nutrient utilization through loss of appetite and reduced absorption.



FIG. 1. Causes of malnutrition

Underlying causes

The numbers of possible underlying causes seem almost endless and their interrelationships complex. All, however, reflect a particular utilization of resources in the past and the present. One way of grouping these causes is to identify a set of outcome conditions necessary for adequate nutrition or, more precisely, for adequate dietary intake and absence of disease. Three such conditions can be identified: adequate access to food (household food security); adequate care of children and women; and adequate access to preventive and basic health services together with a healthy environment. Each of these conditions is necessary but not sufficient for adequate nutrition.

If all three are fulfilled, however, it is likely that dietary intake will be satisfactory, disease will be controlled, and adequate nutrition will be secured.

Household food security is defined here as "access to food, adequate in quantity and quality, to fulfill all nutritional requirements for all household members throughout the year." Household food security is an outcome of technical and social processes in society, but it ultimately depends on the availability, accessibility, and use of resources.

Adequate care of children and women has only recently been fully recognized as having an important bearing on the nutrition status of mothers and children. "Care" refers to caregiving behaviour such as breastfeeding and complementary feeding practices, food and personal hygiene, diagnosing illnesses, stimulating language and other cognitive capabilities, and providing emotional support. Care also refers to the support that the family or community provides to members of the family and to behaviours within the household that determine the allocation of the food supply to members of the household. In addition, care includes the utilization of health services and water and sanitation systems to create a healthy micro-environment for family members.

Care, like household food security, is the outcome of complex processes in society, but it ultimately depends on the availability, accessibility, and use of resources. Important causes of inadequate child care include poor health of the mother; lack of education and wrong beliefs of caregivers; lack of self confidence of the mother; inadequate social support from community, family, and husband; excessive workload of the mother; and mother's lack of control of available resources.

Access to health services, together with a healthy environment, is the third necessary condition for good nutrition. Prenatal and post-natal care, immunization (particularly against measles), oral rehydration therapy, distribution of micronutrient supplements, de-worming, family planning, and health education are all important health services with great impact on nutrition. Access to water and safe excrete disposal are prerequisites for control of diarrhoea and other diseases influencing the nutrition status of children. The achievement of the "health" condition ultimately depends on resources in the same way that the achievement of the "food" and "care" conditions does.

Basic causes

There are three main types of resources: human resources (people, their knowledge, skills, and time); economic resources (assets, land, income, and so forth); and organizational resources (for instance, formal and non-formal institutions, extended families, and child-care organizations).

Resources are available at different levels of society and are controlled in many different ways. At the household level, men usually control more of the resources, which often constrains the achievement of the necessary conditions of food, care, and health.

The use of resources depends on the way a problem is understood as well as on the perception and priorities of those who control resources. Education plays a particularly important role in determining how resources are utilized to secure food, health, and care for children.

The availability and control of human, economic, and organizational resources at different levels of society are the results of historical processes in society. These processes can be seen as the basic causes of malnutrition and can be divided into four groups:

-ecological/technical conditions of production, including the environment (soil and climate), the population-resource ratio, the level of technology used, and the levels of people's skills;
-social conditions of production, including such aspects as the ownership of the means of production, the division of labour, and power relationships;
-political factors (including state interventions), including policies on employment, prices, incomes, subsidies, health, education, and agriculture, as well as the legal system as a whole; and
-ideological factors, including habits, beliefs, cultural preferences, and all ideas that legitimize actions in society.

The development and interaction of these different factors explain the existing availability and control of resources, which in turn explain the degree of fulfillment of the three necessary conditions (food, health, and care) for good child nutrition.

The triple-A approach

Some of the problems causing malnutrition are amenable to effective actions at household and community levels. If decision-making at these levels were more supportive, more women and children would survive, and those surviving would be in better condition. Other problems can be addressed only with support from outside the community (for example, by medical services, which in turn require supplies that may need to be procured outside the country with foreign exchange). International economic and political relations affect decision-making at these levels, with implications for the strategies adopted at the national level and the conditions under which households make their decisions. It is clearly important, therefore, that the critical actions and decision makers be identified and their decision-making processes understood. Processes supportive of women and children should be encouraged and those detrimental changed.

Actions to improve the nutrition situation of women and children involve the reallocation of resources in their favour. Within households, this may mean more time spent by parents with their children, greater sharing of work among adults in the household, and a larger percentage of income earmarked for goods and services of benefit to women and children. At national and international levels, planning priorities might be changed and budgets reallocated. To make decisions to reallocate resources, those controlling the resources need information to justify their decisions.

Decision-making at all levels depends on an initial assessment, which is undertaken only when a problem is perceived and a commitment made to do something about it. Perception and commitment are dependent on the availability of information and the ability to understand the information. Analysis of the problem may be facilitated by the collaborative efforts of people most affected by and knowledgeable about the situation, together with people technically trained to undertake analyses of similar problems. Actions taken to improve the situation after this assessment and analysis may not lead to solutions of all aspects of the problems; they may, however, contribute to creating a new situation that is more conducive to actions that may not have been feasible before (fig. 2).

After this cycle of assessment, analysis, and action, the impact of actions is re-assessed and the situation re-analysed. For this process to take place, there must be an information system in place that must include information not only about the end result of the situation (malnutrition, for example) but also about its causes. In this way, the process will lead to more effective, better-focused actions.

Triple-A processes do not function in a vacuum. A number of factors are critical to their success and must be present to fuel their operation:

-perception and understanding of the nature of the nutrition problem. This influences, in particular, the choice of what is assessed, how it is analysed, and what actions are regarded as feasible;
-effective demand for nutrition-related information and motivation to act. Decision makers need information for designing actions as well as for convincing others that actions are necessary and feasible (creating coalitions);
-capabilities (primarily technical) to obtain information in assessment (monitoring) and to use information in analysis and design of actions;
-resources for the system, that is, for the establishment and maintenance of the nutrition information system, including human, economic, and organizational resources;
-resources for action. When there are inadequate human, economic, or organizational resources available to implement likely action, the focus of the nutrition information system must be to mobilize these resources.

Figure 3 illustrates how these factors influence the triple-A process.



FIG. 2. The assessment-analysis-action (triple-A) cycle



FIG. 3. Factors influencing the triple-A process

Theory and practice of ethics

Ethics or moral philosophy aims at the "understanding of moral concepts and justifies moral principles and theories" [4]. The French revolutionary slogan "liberty, equality, and fraternity" can be used to clarify the historical development of human rights. Liberty is represented by civil and political rights: the right of individuals to freedom from arbitrary interference by the state. Equality refers to social, economic, and cultural rights: the right to food, education, employment, shelter, etc. The state has an obligation to fulfil these conditions. Fraternity refers to rights of solidarity. The rights of developing countries to a more just world economic order belong to this last category [5].

Cultural relativism is another area in which human rights activists face problems. An increasing number of governments, accused of human rights violations, defend themselves by claiming that outsiders should not interfere with the internal affairs of a society, that these alleged violations are part of their internal culture, and that human rights cannot be universal. This raises the question whether the whole concept of human rights is "Western." There is no strong theoretical foundation for proving that this is not the case. It has been argued that when there is an international consensus about a particular set of rights, these rights exist and are universal [6].

Eide [7] has defined three types of state obligation. First, states must respect the freedom of individuals to take actions by using the resources they control. Collective or group actions must also be respected. Second, states must protect individual freedom of action and use of resources from other more assertive or aggressive subjects. Individuals need to be protected from, for example, powerful economic interests and from unethical trade and marketing practices. Finally, states must fulfil the expectations of all to enjoy their rights, either indirectly, by providing opportunities, or directly, by providing commodities or services needed by the individual. The obligation of the state in relation to solidarity rights must be some form of sacrifice. Solidarity reflects an ethical position that poor people and nations have a right to get out of poverty as a matter of principle, even if it would mean reduced economic growth for the richer countries. Solidarity is a right; charity is not.

Towards a rights-based nutrition strategy

Politics has often been influenced by two different kinds of political theory: goal-based theories and duty-based theories. Each of them is founded on correlative moral theories (teleological vs. deontological). Both are forward-looking, both aim at improving the lives of people, and both can pursue goals. But they are different in the different emphasis given to the goal itself and to the means to achieve the goal. They are also different in the approaches of their promoters. Promoters of the first type of strategy more often use scientific arguments, whereas promoters of the second use ethical ones.

Nutrition strategies reflect the same difference.

Goal-based nutrition strategies emphasize the prime needs to achieve certain goals. These goals are legitimized when such an achievement is put to use. Better-nourished children need fewer health services, learn better at school, and grow up to be adults with higher productivity and income. The World Bank is pursuing such utilitarian goal-based nutrition strategies. It often means that the "unreachable" children among the poorest of the poor are left out in the name of maximizing the number of beneficiaries.

Duty-based nutrition strategies emphasize the quality of the process towards achieving goals. Such strategies promote participation, ownership, empowerment, and sustainability. They often focus on the poorest and the unreachable rather than maximizing the number of beneficiaries. Promoters of such strategies tend to be deeply committed and involved in assisting individual poor people. Many non-governmental organizations have adopted this type of strategy.

A rights-based strategy would provide an alternative not yet explored. Such a strategy would include some elements of both a goal-based and a duty based strategy. Psychologically most people find rights more acceptable than duties. Duty for duty's sake is absurd, while rights for their own sake are not. A rights-based strategy would first of all be people based. Poor people would be recognized as key actors rather than as passive beneficiaries of transfers of services and commodities. Participation would not mean that "they" participated in "our" project, but rather that "we" were allowed to participate in "their" work. This would, of course, require a new kind of development worker-someone who knows how to listen and learn, rather than preach and command [8].

The most fundamental right is that of individuals to choose how they shall live. But this can only be a prima facie right, because one person's choice can reduce another person's choices. This will require constant compromises of the kind that only a democratic society can accommodate.

Rights imply goals. In other words, the achievement of a certain goal is a necessary, but not a sufficient, condition for the realization of a right. The World Summit for Children (WSC) nutritional goals represent moral minima, accepted and supported by all major religions and political ideologies. They are what Sen calls "cross-cultural moral minima" [9]. A rights-based strategy requires that these goals be achieved, but that the process of their achievement satisfy deontological criteria, such as empowerment, ownership, and sustainability.

As mentioned earlier, UNICEF promotes a Triple-A approach in its nutrition strategy. Assessment, analysis, and action are influenced not only by the objective understanding of the problem (i.e., a conceptual framework) but also by ethical considerations. This is symbolically illustrated by the heart in the middle of the cycle (fig. 4).

The Convention on the Rights of the Child (CRC) ensures that children have a claim against the state to be well-nourished. A rights-based nutrition strategy promoting the fulfillment of these moral minima would contribute to the development of a non-ethnocentric ethical consensus [10].

A first step has already been taken to initiate a global movement for promoting nutrition as a human right. In May 1994 in Florence, Italy, the World Alliance on Nutrition and Human Rights (WANHR) was launched at a meeting of people from national and international non-governmental organizations and institutions dedicated to pursuing the condition for fulfilling human nutrition needs through the enjoyment of economic, social, and cultural rights.

Countries are used to being compared on the basis of their economic development. Now the time has come when countries should be compared by the way they take care of their children: how well they respond to the obligations they accept when they ratify the CRC. Gradually information from improved monitoring systems can be expected to contribute to an increasing global embarrassment for those countries that have the resources but avoid the necessary political choices to achieve the goals. This will eventually contribute to an environment where it becomes "good politics" to ensure the rights of children and "bad politics" to deny children their rights.



FIG. 4. Ethics and science in the triple-A process

References

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2. Kuhn TS. The structure of scientific revolutions. 2nd ed. Chicago: University of Chicago Press, 1970.

3. UNICEF. Strategy for improved nutrition of children and women in developing countries. UNICEF policy review. New York: UNICEF, 1990.

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5. Freeman M. The philosophical foundations of human rights. Hum Rights Q 1994;16:491-514.

6. Donnelly J. Universal human rights in theory and practice. Ithaca, NY, USA: Cornell University Press, 1989:1, 23-7, 1124.

7. Eide A, Eide WB, Goonatilake S. Gussow J. Omawale, eds. Food as a human right. Tokyo: United Nations University Press, 1984.

8. Chambers R. Rural development: putting the last first. London: Longman Scientific Technical, 1983.

9. Sen A. Poverty and famines. An essay on entitlement and deprivation. Oxford: Clarendon Press, 1982.

10. Crocker D. Toward development ethics. World Dev 1991;19(5):457-83.