A MATERNAL AND CHILD NUTRITION PROGRAM IN COSTA RICA 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 Hospital 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 grams of 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, Moravia, TibBs, This daily snack will be served to chil- Montes de Oca, Curridabat, La U&n, De- dren less than seven years of age, to samparados, Alajuelita, 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&.