0 Nutrition and Health

Sugar. Sugar, by elevating brain levels of serotonin, would be expected to
have a calming effect on behavior (Glinsmann, Irausquin, and Park 1986).
Nevertheless, the suggestion that sugar consumption induces hyperactive
behavior is an old one (Seham and Seham 1929; Randolph 1947; Rinkel,
Randolph, and Zeller 1951), and many parents have been reported to
believe that sugar is a cause of uncontrolled behavior in their children
(Crook 1975). Data to support this idea are limited. One retrospective
review of glucose tolerance curves of hyperactive children found that 75
percent of 261 hyperkinetic children had abnormal glucose tolerance
curves following a j-hour glucose tolerance test (Langseth and Dowd 1978).
Other studies have not found abnormal glucose tolerance curves. An
association was suggested between destructive agressive behavior and
sugar intake in hyperkinetic children, but not in other normal 4-to 17-year-
old children, based on 7-day food diaries kept by the mothers and video-
taped observations of behavior by trained observers blinded to the protocol
(Prinz, Roberts, and Hantman 1980). Another study noted an inverse
relationship between sugar consumption by children and standardized
measures of intelligence and school achievement (Lester, Thatcher, and
Monroe-Lord 1982). None of these studies has shown a cause-and-effect
relationship between sugar and behavior.

One way to study cause and effect, in contrast to correlation and associa-
tion, is with a double-blind challenge study in which subjects are exposed
to a test substance or to a placebo and the results compared. To date,
however, only short-term challenges have been carried out; their results
show little effect. For a group of 21 boys whose families responded to an
advertisement seeking children with adverse behavioral reactions to di-
etary sugar loads, the ingestion of sugar produced a slight but significant
decrease in gross motor activity (as would be expected on neurochemical
grounds), and no differences were found in attentional measures (Behar et
al. 1984). One hyperkinetic j-year-old male and his mother both became
frustrated, hyperactive, and difticult to control after a double-blind chal-
lenge with sugar in lemonade. However, not 1 of 50 other hyperkinetic
children tested in the same way responded to a sugar challenge (Gross
1984).

The effects of acute challenges of sucrose in comparison to the artificial
sweetener aspartame in grade school children were compared using 37
behavioral (playroom observation and examiner ratings) and cognitive
(learning and memory tasks) measures (Wolraich et al. 1985). No differ-
ences in any measure of performance were found. No systematic change in
activity was observed in eight school-aged children exposed to three differ-

526


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ent doses of sucrose or to an aspartame placebo, and no clear effect was
found on the Continuous Performance Task (Ferguson 1984).

To date, the only double-blind challenge that has reported an increase in
activity after consumption of sugar was a pilot study of 13 psychiatrically ill
children given regular orange juice orjuice with sugar added in the form of
sucrose or fructose (Connors and Blouin 1983). A subsequent study of 37
children who were psychiatric inpatients appears to suggest that during
classroom observation less motor activity is seen with the sucrose and
fructose challenges compared with aspartame (Connors 1984a). Overall,
acute challenges with dietary sugar have failed to show that sugar causes
hyperactivity, inattention, or impulsiveness (Rapoport 1986; Ferguson,
Stoddard, and Simeon 1986).

Co&&e. Caffeine has been a concern of consumer groups because of
possible deleterious effects upon children's behavior (Rumsey and
Rapoport 1983). In a series of studies of the effects of caffeine in normal
grade school children, habitual dietary caffeine intake was found to be a
significant predictor of behavior (Elkins et al. 1981; Rapoport, Elkins, et al.
1981; Rapoport, Jensvold, et al. 1981; Rapoport 1983; Rapoport et al.
1984). Children who habitually consumed greater amounts of caffeine
became more anxious and difficult to arouse when they were deprived of
caffeine. When children were challenged with caffeine, the habitually high
consumers felt little effect, but children who normally consumed little
caffeine experienced adverse effects. Because no caffeine was consumed
for 2 weeks preceding the challenge in this study, these effects are not likely
to be due to caffeine tolerance, but instead suggest a possible physiologic
basis for caffeine effects in children.

Considerable research has been conducted on the possible therapeutic
effects of caffeine on behavior in children. In an uncontrolled cross-over
trial with hyperactive children that compared the effects of caffeine, meth-
ylphenidate, and no treatment, caffeine significantly improved behavior
(Schnackenberg 1973). In one study, caffeine has also been reported to
improve the reaction times of hyperactive children (Reichard and Elder
1977), but not in more carefully controlled studies (Huestis, Arnold, and
Smeltzer 1975; Garfinkel, Webster, and Sloman 1975; Firestone et al. 1978;
Connors 1979). Comparisons of caffeine with stimulants such as
amphetamine or methylphenidate have consistently found the prescription
agents to be superior (Garfinkel, Webster, and Sloman 1975; Gross 1975;
Huestis, Arnold, and Smeltzer 1975; Arnold et al. 1978; Firestone et al.
1978). Thus, a therapeutic role for caffeine in hyperactivity is uncertain.

521


13 Nutrition and Health

Hypoglycemia

Hypoglycemia (low blood sugar) can occur either after a fast (fasting
hypoglycemia) or several hours after the consumption of a meal (reactive
hypoglycemia). Many individuals believe they suffer from reactive hypo-
glycemia because they experience symptoms of weakness, confusion, and
irritability after eating sugars or other carbohydrate foods. However, it has
not been possible to document an association between these symptoms and
low blood sugar or insulin levels, and most authorities believe that symp-
toms are due to causes unrelated to blood sugar levels (Green 1981). Some
authors believe a high percentage of patients referred with symptoms of
hypoglycemia have emotional disorders rather than actual hypoglycemia
(Johnson et al. 1980; Ford, Bray, and Swerdloff 1976).

True reactive hypoglycemia is diagnosed by an oral glucose tolerance test
in which the administration of a large dose of glucose is followed by a
collection of blood samples at hourly intervals for the next 5 hours. These
tests are often unreliable (Lev-Ran and Anderson 1981; Charles et al. 1981).
The generally accepted dividing line between normal and abnormal blood
sugar of 50 mg/dl in whole blood may be too high, because lower levels have
been observed in many individuals who experience no hypoglycemic
symptoms (Hofeldt, Adler, and Herman 1975; Cahill and Soeldner 1974).
Only when symptoms of hypoglycemia such as sweating, tremor, anxiety,
and irritability occur at the same time as the documented low blood sugar
level can a valid diagnosis of reactive hypoglycemia be made. Such a
diagnosis may indicate the early presence of a disease such as diabetes.

Antisocial Behavior

Before the 1970's. interest in a possible relationship between diet and
criminal behavior was generally limited to food faddists, but more recently,
scientists have given serious attention to this matter (Hippchen 1978, 1981;
Reed 1977; Rimland 1981; Rimland and Larson 1981; Schauss 1980;
Schoenthaler 1983b). Advocates of a link between diet and criminality do
not agree on a single mechanism by which diet might influence criminal
behavior. Among the suggested explanations are reactive hypoglycemia,
food allergies, and other undocumented adverse reactions to food, to
vitamin and mineral deficiencies, and to toxicities (Feingold 1979; Green
1976; Hippchen 1978, 1981; Rimland 1981; Rimland and Larson 1981;
Schauss 1980; Schmidt, Brajkovich, and Asch 1981; Schoenthaler 1983a,
1983b). Experts in criminology and psychiatry have reviewed these claims
and have strongly concluded that no evidence for such a connection exists.
The studies that purport to show such a link are seriously flawed, lack

528


Behavior 0

appropriate controls, and are subject to bias (Gray and Gray 1983; Gray
1986; Pease and Love 1986).

Implications for Public Health Policy

Dietary Guidance

General Public

Behavioral factors clearly influence food selection, dietary change, and
chronic disease risk, but research in this area is still too preliminary to draw
more than a few implications for the general public; exceptions generally
apply to specific chronic disease conditions. Similarly, beyond the dietary
guidance implications presented in the chapter on obesity, current evi-
dence is insufficient to recommend specific dietary changes to prevent or
treat the eating disorders-anorexia nervosa, bulimia, and pica. Sugar,
certain food additives, and caffeine have been suggested as predisposing
dietary factors to the development of behavioral disorders in children and
adults, but evidence is weak and contradictory, and there is no reason to
expect that a reduced intake of these substances would affect the incidence
or severity of behavioral disorders. In addition, current evidence does not
support any implications at present about the effects of amino acid precur-
sors of neurotransmitters on behavior.

Special Populations

Studies in patients with eating disorders and other chronic disease condi-
tions (reviewed in other chapters of this report) emphasize the importance
of modification of diet-related behavior in these conditions. Such patients
should receive advice from qualified health professionals on the application
of dietary principles appropriate for their conditions. Although evidence
linking dietary caffeine, refined sugars, and food additives to behavioral
disorders is uncertain, their elimination from the diet will not impair
nutritional status and can be recommended to patients on an individual trial
basis.

Nutrition Programs and Sewices

Food Labels

Evidence related to the role of dietary factors in behavioral disorders holds
no special implications for food labeling policies.

529


O Nutrition and Health

Food Services

Evidence related to the role of dietary factors in behavioral disorders
currently holds no special implications for change in policies related to
food programs beyond those suggested by the Dietary Guidelines for
Americans.

Food Products

Evidence related to the role of dietary factors in behavioral disorders holds
no special implications for change in policies related to food products at
this time.

Special Populations

Patients with eating disorders should be provided with ready access to
counseling and assistance in the development of diets that provide safe and
adequate levels of energy and nutrients.

Research and Surveillance

Research and surveillance issues of special priority related to the role of
behavior in the prevention of diet-related chronic disease and to the role of
diet in behavioral disorders should include investigations into:
o Behavioral factors that influence food selection patterns and dietary
change.

o The most effective behavioral methods to encourage appropriate di-
etary changes.

o Behavioral factors that increase the risk for diet-related chronic dis-

ease.

o Behavioral factors that increase the risk for obesity, anorexia nervosa,
bulimia, and pica.

o The prevalence of these eating disorders among different groups.
o Behavioral techniques effective in treatment of these disorders.
o Effects of foods and nutrients on etiology and treatment of behavioral
disorders.

0 Behavioral interventions that increase the long-term effectiveness of
health promotion and chronic disease treatment programs.

530


Behavior 0

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Chapter 15

Maternal and Child Nutrition

Further it must be known that the children
must be fed only milk and pap until they
have grown the front teeth. Then one can
give them somewhat stronger food-bread
softened with milk or in a meat or pea broth.
    Bartholomaus Metlinger
      Kinderbuch (1473)

Introduction

The health and productivity of our society have roots in the quality of the
reproductive experience and the subsequent nurturing strategies of parents
and childhood caretakers. Much can be done to enhance the well-being of
mothers and infants, and adequate nutrition during pregnancy and lactation
is an important component of this process. Societies throughout history
have recognized the unique needs of pregnant and lactating women and
have made special provisions for their health care and nutritional needs.

This chapter reviews key issues related to the nutrition of pregnant women
and lactating mothers and their infants, children, and adolescents and to
the improvement of their health and survival. It also discusses aspects of
chronic disease prevention that especially concern these younger age
groups.

Historical Perspective

Although the unique health status of pregnant women has long been recog-
nized, dietary recommendations for this group have reflected incomplete
knowledge about human reproduction and growth and nutrition. Likewise,
while a healthy, vigorous infant has always been the desired outcome of
pregnancy, only recently has nutrition been recognized as influencing that
outcome.

Infants were weighed at birth during Talmudic times, but it was not until the
17th century that the French obstetrician Mauriceau recognized the health

539


0 Nutrition and Health

significance of adequate birth weight (IOM 1985). Mauriceau's ideas did not
gain currency, perhaps because his estimate of 15 lb as a normal birth
weight was obviously incorrect. It was not until the 19th century that birth
weights, on the basis of their variability, were used as indicators of nutri-
tional status and physical growth (IOM 1985).

Beliefs about the effects that various foods might have on the mother or
child influenced dietary recommendations for pregnant women in the 19th
century. For example, to prevent a child from having an unpleasant disposi-
tion, pregnant women were cautioned against eating salty, acidic, or sour
foods. Obstetrical problems also influenced dietary recommendations.
During the time of the Industrial Revolution, rickets commonly impaired
normal pelvic bone formation. As a result, women who had had rickets in
childhood faced major risks in childbirth, and both maternal and infant
mortality were high. To combat this problem, Prochownick, a German
physician, prescribed a fluid-restricted, low-carbohydrate, high-protein
diet for the last few weeks of pregnancy. Because the infants of women who
followed this diet were smaller and more easily delivered, it became a
standard recommendation for women throughout pregnancy, one that per-
sisted even when rickets, the original reason for it, was no longer a problem
(Worthington-Roberts, Venneersch, and Williams 1985).

In the early 20th century, scientists began to study the relationship of low
birth weight (LBW) to shortened gestation and to infant mortality. After
World War I, attempts to relate food shortages to reduced birth weights
were inconclusive. In 1930, the Finnish pediatrician Yllpo suggested that
infants were at high risk below a birth weight of 2,500 g (about 5.5 lb). The
World Health Organization subsequently adopted this standard, despite
recognition that birth weight below this level is not synonymous with
prematurity (IOM 1985).

Although research on diet and pregnancy did not begin until the 1930's,
obstetric practitioners voiced strong opinions about what pregnant women
should-and should not-eat. Obstetrical authorities commonly warned
the pregnant woman against accepting either advice to ". . . eat largely
because she is eating for two" or to ". . . eat sparingly because if she does
not her baby will be too large" (Danforth 1933), holding the view that the
weight of the unborn child could not be influenced by diet except within
very narrow limits. At the same time, pediatricians argued that the mother's
health and nutritional status did indeed influence the size of the newborn
child. Studies conducted by the Research Laboratory of the Children's
Fund of Michigan demonstrated that the mother's nutritional state before
and at the time of conception and the adequacy of her diet during pregnancy

540


Maternal and Child Nutrition 0

influence the well-being of the infant. There was an upswing of research in
maternal nutrition in the 1940's, influenced by the impact of wartime food
shortages on maternal health (Egan 1987). Some of the famine studies
during World War II showed a marked fetal impact from extreme food
deprivations of the mother, but correlational studies were inconsistent in
relating nutritional intake to birth outcomes (IOM 1985). There was suffr-
cient interest and concern in the United States about the relationship of
maternal nutrition to problems of prematurity, congenital malformations,
and infant mortality to stimulate the National Academy of Sciences to
appoint a Committee on Maternal Nutrition and Child Feeding in 1946. Its
charge was to "implement improved health of the nation through better
coordination of scientific advances in the field of obstetrics and pediatrics."
The Committee's 1950 report, Maternal Nutrition as It Relates to Child
Health-An Interpretive Review, served as the chief reference for maternal
and child health nutrition programs for many years (Egan 1987).

Uncertainties about the role of nutrition in the management of pregnancy
led to discussion between the service community and the research commu-
nity in 1966 that resulted in formation of a Committee on Maternal Nutri-
tion of the National Academy of Sciences. In 1970, the Committee issued a
hallmark research report, Maternal Nutrition and the Course of Pregnan-
cy, stimulating the following:

0 Significant changes in clinical practices related to the routine restric-
tion of weight gain and sodium intake during pregnancy.
0 Reaffirmation of the priority needs of pregnant women and infants in
supplemental food programs.

o Development, adoption, and dissemination of policy statements and
guidelines related to nutrition and maternal health by professional
organizations.

o Increased emphasis on training of nutrition personnel as well as on
education in nutrition for physicians.
o Increased funds for research on maternal and perinatal nutrition, and
renewed interest of the National Institutes of Health in this area (Egan
1987).

Maternal and infant nutrition was a focus of the White House Conference
on Food, Nutrition, and Health in 1969, and its Conference Panel on
Pregnant and Nursing Women and Young Infants identified adequate diet
as one factor "known to be necessary for favorable outcomes of pregnan-
cy" (White House Conference 1969). The panel recognized the increased
and special needs of pregnant and nursing women and infants and con-

541


0 Nutrition and Health

eluded that optimal nutrition for women throughout life is the best way to
promote infant health. In 1970, the White House Conference on Children
called for expansion and improvement of existing food programs as well as
promotion of nutrition education in the schools. In 1971, the White House
Conference on Youth demanded Federal food assistance for all young
Americans in need, and a National Nutrition Education Conference later
that year also focused attention on the nutritional needs of adolescents
(Egan 1972).

Federal Maternal and Child Nutrition Programs

Despite scientific uncertainties about the relation among nutrition and
human reproduction, growth, and development, Federal programs have
addressed the nutritional needs of mothers and children since early in this
century (Egan 1977). The Children's Bureau issued dietary advice to par-
ents and teachers and conducted nutritional surveys of low-income chil-
dren (Egan 1977). School feeding programs began in the early 1900's when
free, compulsory, and universal education was instituted. These programs
were also supported by philanthropic organizations, local school districts,
and private donors. Several States authorized schools to serve meals at
cost, and a few States even served meals at reduced or no cost to needy
children (CBO 1980). Increasing Federal involvement in these programs
resulted from the burden on local and State entities during the 1930's. An
amendment to the Agricultural Act of 1933 established a fund to purchase
surplus agricultural commodities for donation to needy families and to
child nutrition programs, including school lunch programs. The Social
Security Act of 1935 authorized grants to the States for health services for
mothers and children and established the basis for a national program of
nutrition services (including assessment, counseling, referral, and fol-
lowup) for this population (Select Panel 1981).

When the supplies of surplus commodities declined during World War II,
Federal involvement in child feeding programs shifted to general income
assistance. To avoid the uncertainties of congressional appropriation of
cash subsidies, the National School Lunch Act, authorizing permanent
grants-in-aid to States, was enacted in 1946. To receive cash and commodi-
ty assistance, the States had to operate school lunch programs on a non-
profit basis, provide free or reduced-price lunches for needy children, and
serve lunches that would meet specified Federal standards (CBO 1980).

The Child Nutrition Act of 1966 enlarged the scope of Federal efforts by
establishing numerous programs to expand food assistance year round to
children of all ages and to provide assistance to pregnant women and

542


Maternal and Child Nutrition 0

infants. For the first time, high-risk families enrolled in comprehensive
maternity and infant health projects and children and youth projects re-
ceived direct nutrition services as an integral part of their health care (Egan
1977). These programs and policies led to authorization of the Special
Supplemental Food Program for Women, Infants, and Children (WIC) by
Congress in 1972. Modified versions of many of the Federal food assistance
programs that developed during the 1960's and 1970's remain in place today.

U.S. Department of Agriculture Programs. Current food assistance pro-
grams of the U.S. Department of Agriculture (USDA) include:
0 School Breakfast and Lunch Programs: help schools to serve nourish-
ing, low-cost meals to children and to provide free or reduced-price
  meals to children from low-income families.

0 Summer Food Service Program: helps communities serve meals to
needy children when school is not in session. Operates in areas where
the concentration of low-income families is high.
0 Child Care Food Program: subsidizes meals and snacks for children up
to age 18 in nonresidential child care programs.
0 Special Supplemental Food Program for Women, Infants, and Chil-
dren: provides selected foods rich in specific nutrients, nutrition edu-
cation, and health care referrals to pregnant, lactating, and postpartum
women and children up to age 5. Participants must be certified as
nutritionally at risk and of low income.
o Commodity Supplemental Food Program: distributes certain agricul-
tural commodities at no cost to supplement the diets of low-income
infants, children under 6 years, and pregnant and postpartum women
who are vulnerable to malnutrition.

o Special Milk Program: makes it possible for school children to pur-
chase milk at reduced price or receive it free; subsidizes milk served to
children in schools, day care institutions, and summer camps.
0 Food Stamps: provide eligible individuals and households with cou-
pons free of charge that can be exchanged for food at authorized food
stores. The redemption value of the food stamps depends on the
household's size and financial circumstances. Food stamps are meant
to supplement what a family spends on food.

Although there are intrinsic limitations in methods, evaluations of the
school feeding and WIC programs have generally shown that they improve
the health and nutritional status of the target populations (see Systems
Development Corporation 1983; Rush 1985).

543


O Nutrition and Health

Nutrition Programs of the U.S. Department of Health and Human Ser-
vices (DHHS). Nutrition services are an important component of many of
the health and social service programs administered by DHHS. These
programs include:

o Title V Maternal and Child Health Program: provides for nutrition
assessment, dietary counseling, nutrition education, and referral to
food assistance programs to women of childbearing age, infants, pre-
school and school-aged children, adolescents, and children with spe-
cial health care needs served through a wide range of health care
programs. In addition, it supports training in nutrition for nutrition
personnel and other health professionals who lead the development of
nutrition services. It supports nutrition projects of regional and nation-
al significance to advance and improve nutrition services for mothers
and children.

o Medicaid-Early Periodic Screening, Diagnosis, and Treatment: re-
quires assessment of the nutritional status of eligible children and
provision of appropriate referral and treatment services.
o Head Start: provides preschool children from low-income families
with nutritious meals and snacks; provides nutrition education for the
children and their families; and provides training and technical assis-
tance in nutrition for Head Start staff.

o Primary Care-Community Health Centers, Migrant Health Programs:
provide nutrition services as an integral component of these compre-
hensive health care programs.

Nutrition Education Programs. Both USDA and DHHS sponsor nutrition
education programs targeted to parents and children. Major programs are
the USDA Extension Service's Expanded Food and Nutrition Education
Program and Food and Nutrition Program, the Nutrition Education and
Training Program of the Food and Nutrition Service, and the educational
component of the WIC program. DHHS funds maternal and child nutrition
education programs through the programs administered by its various
agencies: the health care programs of the Health Resources and Services
Administration and the Indian Health Service of the Public Health Service,
and the Head Start Program of the Administration on Children, Youth, and
Families of the Office of Human Development Services (Select Panel
1981).

National Goals and Recommendations

Within the past decade, Federal reports and conferences have established
goals and produced recommendations designed to improve the nutrition
and health of mothers and children. Some of these goals and reports are
listed below.

544


Maternal and Child Nutrition 0    -

Healthy People: The Surgeon General's Report on Health Promotion and
Disease Prevention. This report defines broad goals for the improvement
of health and reduction of mdrtality rates among infants, children, and
adolescents. Nutrition is included as a key health promotion strategy to
achieve these goals (DHEW 1979).

1990 National Health Objectives. At least 35 of the 226 specific objectives
to achieve the goals defined by Healthy People are related to nutrition and
the health of pregnant women, infants, children, or adolescents (DHHS
1980). Table 15-l presents a selection of these objectives.

Table 15-l

Seiected National Objectivea to be Achiked by the Year 1990
     Mated to Maternal and Child NutritioW

Pregnancy and Infant Health

o Reduce the national infant mortality rate (deaths for all babies up to 1 year of
age) to no more than 9 deaths per 1,000 live births
0 Ensure that no county nor racial or ethnic group of the population has an in-
fant mortality rate in excess of 12 deaths per 1 ,ooO live births
o Reduce the maternal mortality rate to no more than 5 per 100,000 live births
for any county or for any ethnic group
0 Reduce to no more than 5 percent of all live births the percentage of low birth
weight babies (2,500 g and under)

o Ensure that 85 percent of women of childbearing age can state the special nu-
tritional needs of pregnancy and can understand the hazards of alcohol use
during pregnancy and lactation

o Ensure that virtually all infants receive adequate primary health care, includ-
ing nutrition services, when needed
Fluoridation and Dental Heakhb

0 Eliminate cariogenic foods from school vending machines and school breakfast
or lunch programs

0 Ensure that at least 95 percent of school children and their parents are able to
identify the principal risk factors related to dental diseases and be aware of the
importance of fluoridation in controlling these diseases
Misuse of Alcoholb
0 Reduce the proportion of adolescents 12 to 17 years old who report acute
drinking-related problems during the past year to below 17 percent
o Increase the proportion of women of childbearing age who are aware of the
risks associated with drinking during pregnancy to greater than 90 percent
o Increase the proportion of high school seniors who recognize the risk of alto-
ho1 intoxication to 80 percent or more

545


O Nutrition and Health

Table 15-l (continued)

Nutrition

0 Increase the proportion of women who breastfeed their babies to 75 percent at
hospital discharge and to 35 percent at 6 months of age
o Increase the proportion of school cafeteria managers who are actively promot-
ing the USDA/DHHS Dietary Guidelines to more than 50 percent
0 Ensure that all States include nutrition education as part of required school
health education at elementary and secondary levels
Physical Fitness and Exerciseb

o Increase the proportion of children and adolescents ages 10 to 17 participating
regularly in appropriate physical activities to more than 90 percent
~someobjectivesappiytomcwethanonecategory.
bThegeissuesaredisarssedfwtherinthecheptersondentaldiseases,alcohol,and
obesity*respectively.

Source: U.S. Department of Health and Human Services 1980.

Better Health for Our Children: A National Strategy. A chapter of the
report of the Select Panel for the Promotion of Child Health emphasizes the
importance of nutrition in maternal and child health and gives specific
recommendations for improved information and education, health care
services, and research in nutrition for this population (Select Panel 1981).

Surgeon General's Workshop on Maternal and Infant Heafth. This report
recommends that nutrition services become integrated into all maternal
and child health programs, that maternal and child health professionals
receive improved training in nutrition, and that further research be con-
ducted on infant feeding patterns, the development of dietary patterns and
tastes, and the role of social and cultural factors in human nutrition (DHHS
1981).

Surgeon General's Workshop on Breastfeeding and Human Lactation.
This report recommends specific strategies to promote breastfeeding
through improved public and professional education, health care systems
and support services, and research (DHHS 1984).

Significance for Public Health

Although the precise contribution of nutrition to maternal and infant health
cannot yet be distinguished from genetic, environmental, or behavioral
factors that affect risk, an inadequate diet during pregnancy increases the
probability of a LBW infant, who, in turn, has an increased risk of mor-

546


Maternal and Child Nutrition O

bidity and mortality. Well-nourished mothers who gain appropriate
amounts of weight during pregnancy generally give birth to heavier, healthi-
er babies. Poorly nourished mothers who eat well and gain adequate weight
during pregnancy can greatly improve their chances of giving birth to
healthy infants. Diet is also critical in the control of diabetes, hypertension,
and gastrointestinal disorders when such conditions are present during
pregnancy.

Infant Mortality

In the United States, the infant mortality rate (the number of deaths of
infants under 1 year of age per 1,000 live births) has declined rather steadily
throughout this century, largely due to improvements in control of iafec-
tious diseases, health care, and nutrition. In 1900, the rate was about 100
deaths per 1,000 births; by 1978 it had declined to 13.8 and by 1985 to 10.6
(NCHS 1987~). Recent information suggests that the rate of decrease is
slower than it has been in the past, as indicated by a provisional rate of 10.4
for 1986 (Kleinman 1987). Infant mortality rates in several industrialized
countries are considerably lower-for example, 6.5 and 6.6, respectively,
for Finland and Japan in 1983 (NCHS 1986). However, rates among coun-
tries are not strictly comparable due to differences in definitions.

Although marked improvements in infant survival have occurred among all
racial and ethnic groups, the infant mortality rate among black Americans
remains nearly twice as high as that among white Americans. From 1978 to
1985, the infant mortality rate among whites fell from 12.0 to 9.3 per 1,000,
and that among Native Americans fell from 13.7 to 9.1 per 1,000. The rate
among black Americans, however, was 23.1 in 1978; it declined, but in 1985
it was still l&2-nearly twice the rate of whites (NCHS 1987b).

Low Birth Weight

In the United States, the most important factor contributing to the infant
mortality rate is a low birth weight-less than 2,500 g, or 5.5 lb. Low birth
weight occurs as a result of birth prior to 37 weeks' gestation, intrauterine
growth retardation, or both. Infant deaths and illnesses increase sharply as
birth weight declines within the normal weight range and even more sharply
below 2,500 g. They are highest among infants of very low birth weight
(VLBW), below 1,500 g. LBW infants are at increased risk for developmen-
tal handicaps, birth defects, respiratory and other infectious diseases,
behavior problems, and complications of medical interventions. These
conditions greatly increase the emotional and financial burden to the
infant's family and to the Nation (IOM 1985).

547


Ll Nutrition and Health

Although overall rates of infant mortality have decreased greatly, the
prevalence of LBW has declined more slowly. In 1971, babies with weights
below 2,500 g accounted for 7.6 percent of all live births; in 1985, they
accounted for 6.8 percent. Infants of moderately low birth weight (1,500 to
2,500 g) accounted for over 5.5 percent of all live births in 1985 and those of
VLBW for over 1.2 percent. Together, the 6.8 percent of infants. born at
weights less than 2,500 g are responsible for 67 percent of all infant deaths
during the first month of life and approximately 60 percent of all infant
deaths (NCHS 1987a).

Much of the higher infant mortality among black Americans is explained by
the high proportion of LBW infants born to this group. LBW infants
comprised 12.4 percent of all black births in 1985. For Americans of Puerto
Rican descent, the percentage of LBW infants was 9.1. It ranged from 6.2
to 6.9 percent for Americans of Japanese, Filipino, other Asian and Pacific
Island, and American Indian ancestry, and from 5.6 to 5.8 percent for
Mexican, Cuban, and other white Americans. The lowest percentage of
LBW (5.3 percent) occurred among Chinese Americans (Secretary's Task
Force 1985). Of special concern in these figures is the continuing racial
disparity in birth weight. Between 1973 and 1983, rates of moderately low
birth weight decreased more among whites than among blacks. Overall
rates of VLBW decreased, but they actually increased among blacks
(Kleinman and Kessel 1987).

Risk Factors for Low Birth Weight

Medical, social, behavioral, and dietary factors before and during pregnan-
cy contribute to the risk for LBW. Medical risk factors include a previous
reproductive history that includes many pregnancies, anemia, hyperten-
sive disorders of pregnancy, inadequate weight gain, or delivery of a LBW
infant; low prepregnancy weight; chronic illnesses such as diabetes or
hypertension; and poor weight gain during pregnancy. Social, demograph-
ic, and behavioral risk factors have been identified as low socioeconomic
status, low educational level, minority race, single marital status, adoles-
cence, inadequate prenatal care, and use of drugs, alcohol, or cigarettes.

Dietary risk factors include an inadequate intake of calories or essential
nutrients such as protein, vitamins, and minerals. Evidence indicates that
the more of these risk factors present, the greater the risk to mother and
child (IOM 1985). Because these risk factors interact and affect one an-
other, it is difficult to determine the role of nutrition separate from these
other risk factors.

548


Maternal and Child Nutrition 0

Estimates of Cost

The personal cost of the death or severe illness of a LBW infant is incalcula-
ble. Quantitative estimates of the economic costs of care of LBW infants
have been published. In 1987, the average hospital cost was estimated at
$12,000 to $39,000. Costs increase, however, as birth weight falls; the
average cost for a VLBW surviving infant is $3 1,000 to $7 1,000. For infants
born at under 750 g, the average hospital stay was 98 days, and the costs
ranged as high as $150#30 (OTA 1987). In 1984, the rehospitalization rate
during the first year of life was 38.3 percent for VLBW infants and 19
percent for moderately LBW infants. Such infants remained rehospitalized
an average of 16.2 and 12.5 days, respectively. In addition. nearly 20
percent of LBW infants who survive will have long-term morbidity during
the first year that requires medical care (IOM 1985). Even taking into
consideration the increased costs of providing adequate prenatal care. the
savings to the Nation from prevention of even a small proportion of LBW
infants would be considerable.

Scientific Background

Pregnancy and Lactation

Normal pregnancy is accompanied by anatomical and physiologic changes
that are necessary to promote fetal growth and development and prepare
the mother for labor, birth, and lactation. Many of these changes are
apparent in the early weeks of pregnancy.

Physiologic. During both pregnancy and lactation, hormonal changes af-
fect retention, utilization, and excretion of nutrients (Hytten and Leitch
1971). These changes lead to physiologic adjustments that result in expan-
sion of blood volume and accumulation of fluid. They include an increase in
cardiac output, heart rate, and basal metabolic rate. Preparation of the
mammary glands for lactation begins during pregnancy, when the duct
system enlarges and the alveolar cells proliferate. Lactation is initiated and
maintained by hormonal changes that occur in response to the infant's
sucking stimulus. Milk proteins, lipids, and lactose are synthesized by the
alveolar cells. Stored fats are secreted into the milk, as are a variety of
nutrients and other compounds. Although recent evidence suggests that
lactation is associated with physiologic changes that conserve energy and
reduce the need for increased energy intake (Butte, Garza, Stuff, et al.
1984). additional studies are needed to evaluate this matter (Lawrence
1985).

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0 Nutrition and Health

Biochemical. During pregnancy, decreases in plasma concentrations of
albumin, most minerals, and most water-soluble vitamins occur as a result
of the dilution effect of the expanded plasma volume. Because expansion in
red cell mass is not as great as the expansion in plasma volume, the
hematocrit, which is the percentage of red blood cells in a sample of
centrifuged blood, typically drops during pregnancy. Other nutrients, how-
ever, increase in plasma concentration, perhaps as a result of improved
intestinal absorption.

Physical. During pregnancy, body weight, lean body tissue, and fat in-
crease. Increases in tissue fluid levels are most significant in the third
trimester, but women vary substantially in the timing and degree of fluid
accumulation. After childbirth, blood volume and extracellular fluids re-
turn to prepregnant levels. The uterus also returns to normal size, but
breast size remains enlarged throughout lactation. Loss of the body fat
stores accumulated during pregnancy occurs gradually and is usually com-
plete by the time the nursing infant is about 6 months old (Lawrence 1985).

Normal Growth and Development

In humans, intrauterine growth and development require about 40 weeks of
gestation. From the third month until term, fetal weight increases nearly
500-fold, from about 6 g (0.2 oz) to 3,000 to 3,500 g (6.5 to 7.6 lb) at birth.

Znfants. Immediately after birth, weight is lost, but birth weight is usually
regained by the 10th day. After this time, weight increases at a rapid but
decelerating rate. Most infants double their birth weight by the age of 4
months and triple it within 1 year. Length increases by 50 percent during
the first year. These changes are accompanied by changes in body com-
position. Fat accumulates rapidly; by 6 months, it makes up about 25
percent of the total body weight. During the second 6 months, the relative
increase in lean body mass is much greater than the increase in fat (Fomon
et al. 1982).

Children and Adolescents. The very rapid rate of growth in infancy is
followed by slower growth during the preschool and early school-age
years. Weight gain approximates 2.5 kg/year until 9 to 10 years of age.
Length increases by an average of 11 to 12 cm in the second year, about 7
cm during each of the next three. Children become leaner between 6
months and 6 years, after which a gradual increase in fat thickness occurs
in both males and females until puberty; females have a relatively greater
body fat content than males at all stages of development (Fomon et al.

550