003 1-3998/90/2803-0235$02.00/0 PEDIATRIC RESEARCH Vol. 28, No. 3, 1990 Copyright O 1990 International Pediatric Research Foundation, Inc. Printed in (I.S. A The Long-Term Effects of Early Kwashiorkor Compared with Marasmus. IV. Performance on the National High School Entrance Examination JANINA R. CALLER, FRANK C. RAMSEY, DEBRA S. MORLEY, ESTHER ARCHER, AND PATRICIA SALT Center f6r Behavioral Developmmt and Mental Retardation, Boston University School of Medicine, Boston, Mussach~lsetts021 18 and Department of Pediatrics, Queen Elizabeth Hospital, Bridgetown, Barbados ABSTRACT. This is one of a series of studies on the long- However, the previously malnourished children had continuing term effects of early childhood malnutrition in Barbadian deficits in cognitive and behavioral functioning through the school children. This is the first report of the relationship school years, which included impaired IQ performance (2) and between early malnutrition and later performance on a attention deficits reported by teachers and parents (4). Socioeco- national examination administered to all 11-y-old children nomic and home environmental factors during childhood and in Barbados to assign high school seats. We compared adolescence did not play a major role in these findings. scores achieved on the 11-plus examination by 103 boys The opportunity presented itself to use the results of the 1 I- and girls with histories of marasmus or kwashiorkor with plus examination administered to all I 1-y-old children in Bar- those obtained by 63 healthy comparison children and also bados. Scores achieved on this national examination were used with scores obtained by the total island population of by the Barbadian Ministry of Education to rank children for children during the same years. We report that children assignment to local high schools. The highest ranking children with histories of either type of malnutrition confined to were assigned to academic-oriented schools and lower ranking infancy had significantly lower scores on the national high children were, in many cases, assigned to trade schools. Perform- school examination than healthy comparison children. Re- ance on the 1 1-plus examination therefore was likely to have a duced 11-plus scores were closely associated with teacher major long-term impact on the future careers and opportunities reports of attention deficits in the classroom documented available to the children. To our knowledge, this is the first study when the children were as young as 5 to 8 y of age and relating performance on a national examination to a carefully also with IQ and academic performance. Early malnutrition documented history of infantile malnutrition. This supplements had independent effects on performance on the 11-plus other published reports, including our own, of the association examination even when home environmental conditions between poor nutrition and educational performance (5, 6). We were controlled for. These findings have important impli- now report that children with histories of marasmus or kwashior- cations for future opportunities available to children with kor confined to infancy had significantly lower scores on the histories of infantile malnutrition. (Pediatr Res 28: 235- national high school examination than did healthy comparison 239,1990) children. Reduced scores were closely associated with teacher reports of attention deficits in the classroom documented when Abbreviations the children ranged in age from 5 to 11 y. IQ, intelligence quotient MATERIALS AND METHODS ANOVA, analysis of variance MRA, multiple regression analysis Description of study population. This study was undertaken at the National Nutrition Centre, Bridgetown, Barbados, in coop- eration with the Ministries of Health and Education of Barbados. From 1967 to 1988, the Centre provided medical care and nutritional surveillance for children with varying degrees of In a series of studies in Barbados (1-3), we have followed the malnutrition from infancy to 11 y of age. Thorough documen- growth and behavioral development up to 18 y of age of boys tation was available on approximately 2 100 children with or at and girls with histories of marasmus and kwashiorkor in the first risk for malnutrition (7). year of life and have compared the findings with those obtained Procedures to select participants in this longitudinal study from healthy Barbadian control children matched by age, sex, have been described in earlier papers of this series (1-3). Briefly, and socioeconomic group. There was no evidence of continuing the children represented nearly all children on the island of malnutrition in this group and follow-up after puberty of boys Barbados who were born between 1967 and 1972 and who and girls in this category demonstrated catch-up growth that gave experienced a single episode of malnutrition in their first year of them the same body dimensions as the control children (1). life. All children were examined by one of us (F.C.R.) and admitted to the hospital for a period of approximately 30 d with Received January 25, 1990; accepted April 23, 1990. Reprint requests: Dr. Janina R. Caller, Center for Behavioral Development and a diagnosis of marasmus [moderate to severe weight loss below Mental Retardation, M921, Boston University School of Medicine, 80 East Con- 75% of expected weight for age according to the Gomez scale (8) cord Street. Boston, MA 02 1 18. and the absence of edema] or kwashiorkor (characterized by skin This research was conducted with the cooperation of the Ministries of Health changes, edema, and hair changes). Criteria that were satisfied and Education, Barbados, and was supported by grants from the Ford Foundation and The Thrasher Research Fund. F.C.R. was supported by the Milbank Fund and for the current investigation were: I) birth weight 25 Ib, exclud- the W.T. Grant Foundation. This research was a~orovedbv the Boston Universitv' ing cases of fetal growth retardation, 2) absence of any pre-, School of Medicine Institutional Review Board f'o; ~umanSubjects. pen-, or postnatal comp~icationsby history, clinical examination, 235 GALLER ET AL. and Apgar scores, and 3) absence of encephalopathic events were recorded for both semesters of the school year by a school during childhood. After the episode of malnutrition, all children official using local school records and coded numerically (5). were enrolled through 11 y of age into the National Nutrition Because of the range of ages, the children were not enrolled in Centre, where families were provided with a program of nutrition all academic subjects simultaneously. Five major academic sub- education, subsidized milk, routine health care, and home visits jects were tested: reading (including comprehension), language by a team of community health sisters. Adequate nutrition and arts (including oral recitation, composition, grammar, English, good health were assessed by physical examination and red blood discussion, and spelling), mathematics, general science, and so- cell counts. cial science (social education and social studies). Previously malnourished children were matched by sex, age, Socioeconomic and home environmental conditions. We have and handedness (for neurologic tests) with healthy classmates reported on details concerning a questionnaire administered to from the same socioeconomic background (comparison group). the primary caretaker by a community health sister who was Three classmates were randomly selected as a possible match for generally familiar with the home (1 1). Briefly, items on the each index child, and final selection was based on access to birth questionnaire were classified by a principal components factor and health records and parental permission. Comparison chil- analysis with normal varimax rotation. This analysis grouped dren met the same selection criteria as the previously malnour- related items into nine independent factors, including: I) socio- ished children, but were documented by local health clinics as economic characteristics of the home, 2) adult interaction with having adequate growth and nutrition during childhood. Only a the child and amount of stimulation in the home, 3) level of few children were excluded on the basis of growth failure; exclu- maternal education, 4) number of caretakers, 5) type of trans- sion was generally based on being unable to find complete birth portation used, 6) type of and hours of mother's work, and 7) and growth records. Comparison children were in the correct presence of the father or adult males in the home. grade for age even when they were matched to index children (n Data analysis. All analyses were performed using the Statistical = 37) who were not in the correct grade. Package for the Social Sciences (12). Eleven-plus scores were In our study, 39 children with histories of kwashiorkor (a compared using a two-way ANOVA (sex x nutritional history), subset of 65 we have followed previously), 64 children with supplemented by a Student Newman-Keuls test to determine histories of marasmus (a subset of the original sample of 129), which groups differed when a significant nutritional history effect and 63 comparison children (also a subset of an original sample was found. Pearson correlations were used to correlate 1 1-plus of 129) were included. This represented the total number of scores with IQ scores, factors scores describing classroom behav- children for whom the 1 1-plus scores were available at the time ior and marks in school obtained when the children were 5- to of our survey, conducted when the children were 1 1 to 18 y old. 1 1-y-old, and also with factor scores describing socioeconomic There were no differences between the participants and children characteristics of the households. MRA was used to calculate 1 1- excluded in the current survey with regard to IQ scores or plus scores corrected for socioeconomic factors (residual scores). socioeconomic characteristics of the household. Measures. Evaluations included 1 1-plus scores, cognitive and behavioral outcomes, and socioeconomic and home character- istics. All testers were blind to the nutritional history of the child.