A MATERNAL AND CHILD NUTRITION PROGRAM IN l

Dr. Carlos Diaz Amador ’

The author describes the results of a program to bring about the recovery of seriously undernourished children and help keep them well-fed by providing health, nutritional, and so- cial education to the family.

Introduction whole milk and 70,000 pounds of skim milk per month. The amount of money collected Ignorance, unsanitary housing conditions, and inadequate nutrition are common deter- for their support by various committees has minants of disease in low-income families, reached 442,397 colones S per year. particularly among children, whose active The fight against undernutrition begins development renders them particularly vul- in the health units. Here, an evaluation is nerable to the effects of malnutrition. made of the nutritional condition of the From the moment of conception, the child child, his diet, and the supplementary food is exposed to the adverse effects of poor nu- he requires; the mother is given dietary trition in the mother. Continued and direct training, her own nutritional state and her exposure to such deficiencies after birth is diet during pregnancy are appraised, and likely to retard the child’s growth and de- her supplementary food requirements are velopment, leaving him ill-equipped bio- indicated. Relying on these units and on logically to cope with the many factors or the distribution of whole and ski milk and agents conspiring against his health. the availability of funds collected by special committees, Costa Rica has drawn up a plan to combat undernutrition and facilitate Nutritional Centers for Mothers and the recovery of underfed mothers and chil- Children dren in areas of the country where the prob- Costa Rica has the following facilities for lem is of serious proportions. a program against malnutrition in mothers and children: 104 nutrition centers; four Plan for a Campaign against Malnutrition nutrition rehabilitation centers with a com- bined capacity to treat 80 children at a This campaign begins in the children’s or time over a IO-hour stay; and one nutrition prenatal clinic of the health centers men- rehabilitation clinic, equipped to treat 40 tioned above. children at a time during a 24-hour stay. In the child care clinic the following ac- The centers provide nutritional care to tivities are carried out : a monthly average of 13,271 unweaned Evaluation of the nutritional condition children, 29,467 preschool-age children, of the child. This evaluation is based on and 2,424 pregnant women. the three degrees of malnutrition defined by They also distribute 50,000 pounds of Dr. Federico G6mez,4 and on the normal- weight category shown on the weight chart ll’ublished in Spanish in Bolerin de la Oficina .. Sanitaria Panamericana Vol. LXN, No. 6 (June 1968), pp. 411-416. *A Costa Rican colon is quoted at approximately a Director, Nutrition Department, Ministry of Public US$O.15. Health, San Jo&, Costa Rica, and Associate Professor 4A Mexican pediatrician and Director of the Chil- of Preventive Medicine, Umversity of Costa Rica. dren’s of Mexico City. 30 Diaz Amador - MATERNAL AND CHILD HEALTH IN COSTA RICA 31 that accompanies the medical history of teen every day during that period for a sup- each child. plementary meal (consisting of milk, an Evaluatiqn of the diet. The child’s diet omlet with butter, vegetables, etc.), rather is evaluated on the basis of the nutrition than taking it home. report accompanying the weight chart. Stress A similar permit to receive the daily should be placed on teaching mothers the supplementary &eal in the canteen of the value of certain foods that for one reason or nutrition center is issued to properly nour- another are not being used, or are not con- ished children whose family is in a diEcult sumed in appreciable amounts, but that linancial situation that might jeopardize are readily available and can be helpful in their nutritional state. combatting nutritional deficiencies in the Visits should be made to the home to child. make certain that the supply of powdered Provision of supplementary foods. The milk is being used correctly, and special at- physician in the health unit will issue written tention should be given by the health units authorization for the nutrition center to pro- to the periodic examination of undernour- vide supplementary food in the following ished children, who should, of course, be amounts per two-week period: examined more frequently than those in a 1. A maximum of 453.6 grams of whoIe sound nutritional state. milk to children of less than one year con- Nutrition education. The training given sidered to be in the category of first-degree to mothers in the health units in regard to malnutrition. the feeding of their children should deal 2. A maximum of 907.2 grams of whole milk with the following subjects: to children of less than one year considered to be in the category of second-degree malnu- (a) Supplementary feeding of the un- trition. weaned child, based on the premise that by 3. A maximum of 1,360 kilograms of whole the end of his first year his diet should include milk to children of less than one year con- the greatest possible variety of foods. sidered to be in the caregory of third-degree (b) Feeding of the child after he is weaned. malnutrition. (c) The causes of malnutrition in the child 4. A maximum of 456.6 gramsof skim milk and the foods that would aid in his recovery. to children from one to two years of age con- (d) The causes of diarrhea in the child sidered to be in the category of first-degree and the foods that would aid his recovery. malnutrition. The training should be accompanied by 5. A maximum of 907.2 grams of skim milk to children from one to six years of age practical demonstrations of the proper considered to be in the category of second- method of selecting and preparing foods. degree malnutrition. In the prenatal clinic the following nu- 6. A maximum of 1,360 kilograms of whole milk to children from one to six years of age tritional services are performed: considered to be in the category of third- Evaluation of the nutritional condition degree malnutrition. of pregnant women. This evaluation is The written authorization should not be based on the woman’s weight at the onset valid for more than two months, so that the of pregnancy and the gain in weight during mother will be obliged to return to the clinic pregnancy, as indicated by the weight chart with her child at the end of that time for and table attached to each prenatal case its renewal. history. In the case of children from two to six Evaluation of the diet. The diet should be years of age who live near a nutrition cen- evaluated on the basis of the nutrition re- ter, the physician in the health unit will port attached to the prenatal case history. issue an authorization, valid for six months, The evaluation should be followed by ap- allowing them to come to the center’s can- propriate recommendations, and an effort 32 BOLETiN DE LA OFICINA SANITARIA PANAMERICANA should be made to impress on the mother dren in Costa Rica show that 60 per cent that compliance with those recommendations of those visiting the health units are suffer- is important to the health of the unborn ing from malnutrition, are under the nor- child and will increase the possibilities for mal weight and height, and are retarded in successfulbreast-feeding. their psychomotor development and ex- Provision of supplementary foods. A per- tremely susceptible to infectious disease. mit will be issued to pregnant women whose It has been verified that the network of initial weight or weight gain is insufficient, centers described above is sufficient for so that the nutrition center can provide fighting undernutrition but not for effecting them with 453.6 grams of powdered skim the total recovery of seriously undernour- milk per two-week period. ished children. For various reasons, mainly Nutrition education during pregnancy and financial, the hospitals are unable to keep lactation. The prenatal clinic of the health the seriously undernourished children for the units should provide training to the preg- length of time required for full recovery, nor nant women regarding the diet they need can the health units or nutrition centers during pregnancy and lactation and the cope with this problem in a satisfactory way. importance of mother’s milk in the feeding Consequently, a plan has been drawn up of newborn children. for attacking the problem in the areas where The volunteer committees of the nutri- it is most acute. This scheme is based on tion centers will organize and operate two concerted action by the units and centers, types of feeding services in each center: a supplemented by a nutrition clinic and a daily service and a fortnightly service. The nutrition rehabilitation center. daily service, open every day of the week except Sundays and holidays, will provide a snack which will be served at mid-morn- Nutrition Rehabilitation Plan ing (between 8:30 and 9: 30) so as not The proposed area of service of the nu- to interfere with either breakfast or lunch trition rehabilitation plan comprises the eaten at home. districts of Guadalupe, , TibBs, This daily snack will be served to chil- , , La U&n, De- dren less than seven years of age, to samparados, , Escazfi, and the pregnant women, and to nursing mothers Central District, all in the metropolitan area who live near the nutrition center and have of San Jo&. the required permit from the physician of The objective of this plan is the nu- the health unit. trition rehabilitation of children up to six The fortnightly service consists in pro- viding whole or ski powdered milk-the years of age residing in these districts and amount depending on the age or other suffering from acute malnutrition (third de- characteristics of the recipient-to children, gree malnutrition, according to the G6mez pregnant women, and nursing mothers who classification). In addition to this, an at- have the necessarypermit from the physician tempt will be made to encourage the families of the health unit. of malnourished children to visit the local The nutrition center committee is au- health services (health unit and nutrition thorized to request a contribution of half center) ; to improve the mother’s and a colon for each pound of skim milk to family’s knowledge of personal hygiene and help defray the cost of the service it pro- nutrition, and to help the families organize vides. their finances more efficiently and make Nutritional evaluations of children under better use of the resources available in the one year of age and of preschool-age chil- community. Diaz Amador * MATERNAL AND CHILD HEALTH IN COSTA RICA 33

First Stage 0 Determination and treatment of all in- fectious conditions interfering with proper as- Health units. All children, including those similation of food. released after treatment in the Children’s l Education of the mothers in regard to Hospital, should be registered with the nutrition through individual and group coun- seling and instruction in cooking. health unit having jurisdiction in the place l Social work to assist the family in solving where they live. Here their nutritional con- some of its economic and social problems, dition will be evaluated and their degree of especially those that hinder proper distribution undernourishment, if such exists, will be of the family budget and proper use of the determined. They will also be subjected to resources available in the community. l Health education for the home, intended routine analyses (feces and urine), a hemo- to correct defects or omissions in personal gram will be taken, and they will be tested hygiene and family diet. for total or partial proteinemia. l Provision of powdered milk to the under- The children will also be inoculated nourished child, in sufhcient amount to sup- against diphtheria, poliomyelitis, and tu- plement the home diet and satisfy his nutri- tional requirements. berculosis (with BCG), and the mothers will be given health training, especially as After these steps are taken, if the child’s regards personal hygiene and nutritional nutritional status shows no improvement, he habits and practices. will be sent to the Nutrition Rehabilitation Nutrition centers. These centers will pro- Center in Tres Rios, where the third stage vide powdered milk in sufficient quantity to of the plan will go into operation. supplement the home diet and satisfy the protein and calorie requirements of all chil- Third Stage dren to whom authorizations have been Nutrition rehabilitation center. This cen- issued by the proper health units. ter is operated by the Social Welfare Board After this tist stage, which will generally of the District of La Union and is available take three months, children whose nutritional only to children showing no signs of nutri- condition is still classified as one of third- tional recovery after undergoing the first degree malnutrition will be sent to the nu- and second stages of the plan. trition clinic in the Cristo Rey section of Another admission requirement is that the city of San Jose. the child must not be suffering from syphilis or tuberculosis and must not be a carrier of Second Stage diphtheria bacilli or enteropathogenic germs (Salmonella). Nutrition clinic. This clinic offers out- While the child is still at the nutrition patient consultation services for all children rehabilitation center, his family will be given under seven years of age referred by the hygienic, nutritional, and social training by health units serving the area covered by the appropriate units, so that when the the plan. child returns home he can receive appro- The nutrition clinic will try to determine priate care that will ensure complete and and, to the extent possible, eliminate, all lasting recovery. the factors contributing to the child’s under- nourishment, This work will be done by a Summary team consisting of a pediatrician, a social worker, a nutrition auxiliary, and a rmrs- A scheme is being put into practice in Costa Rica to cope with maternal and child malnu- ing auxiliary. The objective will be to bring trition. It is based on a network of health units about the nutrition rehabilitation of the -104 nutrition centers giving monthly treat- child by the following means: ment to 13,271 unweaned children, 29,467 34 BOLETiN DE LA OFICINA SANITARIA PANAMERICANA preschool-age children, and 2,424 pregnant living in certain districts of San Jose and suf- women; four nutrition rehabilitation centers fering from third degree (acute) malnutrition with a capacity to treat simultaneously 80 are entitled to take advantage of the authoriza- children over a lo-hour stay; and a nutrition tions issued by the health units to obtain food rehabilitation clinic capable of treating 40 supplements in the nutrition centers. If children simultaneously during a 24-hour stay. after he has received such supplements for a The infant consultation and prenatal care certain period of time the child’s nutritional departments of the health units check the nu- status shows no change, the case is referred to tritional status and diet of children and preg- the nutrition clinic, where it is studied and nant women, and issue authorizations to ob- the mother given instruction in regard to diet tain whole or skim milk from the nutrition and personal hygiene. Finally, if there is centers or for snacks at the unit’s canteen to still no change for the better, the child is sent supplement the diet. to the nutrition rehabilitation center, where In addition, another nutrition rehabilitation treatment is continued while the family is scheme has been drawn up for areas in which given nutritional and social guidance so that the problem is becoming more severe. Under when the child returns home he can be prop- this scheme, all children up to the age of 6 years erly cared for and enjoy a full recovery.