editor: B. Bradfleld,
Robert
J.D.,
international
Ph.D.
nutrition
Nutrition, infant behavior, and maternal characteristics: a pilot study in West Bengal, India1’2 Pirkko
Lauslahti
Graves,3
Mag.
ABSTRACT
Free
among
undernourished
Bengal.
The
the
mother,
her
more
lower scores
Phil.,
and
especially frequently
revealed
maternal
scores Nutr.
boys
than
in four
and
mother-child
well-nourished
did
reciprocity
showed
a divergent
29: 305-3
19, 1976.
boys. The not different. pattern
Journal
of Clinical
Nutrition
29: MARCH
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/3/305/4648806 by guest on 08 February 2018
the ages activity,
and The
behavior.
in mother-child
Malnutrition is a complex product of economic, social, biological, and psychological factors (1-3). Its impact on human behavior and development ranges from biochemical and physical to psychological changes, which may even extend over generations (4-6). Among the psychological changes, learning ability is the most frequently documented function affected by malnutrition (3, 7-9). The link between malnutrition and learning ability is complex (1), and the following possibilities are offered to define a causative linkage: central nervous system damage; reduced learning time and/or responsiveness as a result of malnutrition; or interference of malnutrition during critical periods of learning (7). One critical period of learning is that of early infantile experience, which is strongly influenced by the nature of the infant’s relationship with his mother (10, 11). The mother is the source of the infant’s physical and emotional satisfaction, and acts as a mediator and a source of stimulation for the infant. Total or partial failure in either of these The American
boys.
of maternal
undernourished boys were
in play
a distance,
the well-nourished
in a standard
between
less vigor
across
of six measures
a high
interaction
children
showed
in interaction
of reciprocity for the well- and undernourished J. Clin.
activities
undernourished
scores
Ph.D.
setting
of 7 and
were
18 months
less attachment
maintained mothers
close between
physical child
interaction
for the well-nourished
developmental However,
quotient and activity the correlations between
of relationships
for the two
nutritional
in West
behavior
toward
contact
of the undernourished
Correlations
observed
with
boys and
boys,
had
maternal but
a lack
scores of the these and the
groups.
Am.
major functions of mothering may adversely affect the infant’s intellectual and socioemotional development, as shown in studies on maternal deprivation and separation ( I 2, 13). Conversely, mothering which provides environmental stimulation and enrichment may have long-term enhancing effects on the infant’s cognitive and socioemotional development, as shown by studies on psychosocial enrichment (13). The contemporary trend in child developmental research, with its emphasis on studying
the
ongoing
mother-child
has advanced our knowledge maternal care components specific infant development
relationship,
of the specific that influence components in
‘From the Department of Pathobiology, The Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland 21205. 2This project was supported by Grant 5 R07 A1I0048-14, awarded by the National Institutes of Health, Department of Health, Education, and Welfare to the Department of Pathobiology, The Johns Hopkins University School of Hygiene and Public Health. International Center for Medical Research. ‘Assistant Professor.
1976,
pp.
305 -3I9.
Printed
in U .S.A.
305
306
GRAVES
both the intellectual and socioemotional spheres (I 1, 14-17). The findings support the notion that mutual adaptation and reinforcement between the mother and the young child play an important role in the child’s psychological growth ( 1 1 , 18-19). The purpose of the present study was to explore whether differences in specific cornponents of infant behavior and of maternal behavior could be detected between poorly nourished and adequately nourished young children. An assessment of behavioral differences and differences in mother-child interaction would be a necessary first step toward the goal of specifying the influence of early infantile experience on the malnourished child’s development, including learning. Based on theoretical considerations and on the existing research evidence, four major behavioral categories were selected for the assessment. The first and second categories were the child’s attachment behavior toward the mother and maternal behavior toward the child. As stated, the role of the mother is not only important for the infant’s physical and socioemotional development, but it also influences the infant’s intellectual development (11, 14, 20). The child’s attachment behavior,
that
is,
behavior
that
promotes
contact and/or proximity to the mother (16), gives information about the nature of the mother-child tie. A secure tie enables the child to maintain a dynamic balance between his attachment and exploratory behaviors (16). An insecure tie, in contrast, disturbs this balance and contributes to deficits in exploratory behavior as well as to a poorer intellectual performance (21). The child’s irritability, in the form of whimpering and crying, was selected as a third behavioral category. Although basically attachment behaviors (16), whimpering and crying reportedly are characteristic behaviors among malnourished children (22, 23). The child’s exploratory behavior was selected as the fourth category because it plays a central role in intellectual development. A large body of recent experimental work provides evidence that intellectual ability is influenced by experience, in particular by early infantile experience (10, 11, 15). Through exploratory behavior the infant expands his experience and acquires
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/3/305/4648806 by guest on 08 February 2018
and exercises new skills. Concerning malnourished children, it has been suggested that the attendant low level of activity may not only interfere with the child’s capacity to explore, but would also elicit less response from the mother, which in turn would contribute to retarded behavioral development (3, 24). Moderate malnutrition, that is, chronic undernutrition, characterized by restricted food intake both in quantity and in quality (3), was selected for study, rather than severe forms of malnutrition caused by inadequate food intake (kwashiorkor, marasmus) (3). Severe cases were available, but were avoided in the present study because the worldwide problem is chronic undernutrition (25). If behavioral alterations could be detected among the undernourished children when compared with adequately nourished children, the findings would have wider implications than would findings from severely malnourished children. Subjects The study
and
methods
area
The study was done in Singur District, West Bengal, India, between November 1971 and June 1972. The district, composed of a dozen or so adjacent small villages within an area of 57 square miles, is located approximately 25 miles northwest of Calcutta and has good highway and railway connections with Calcutta. The population is approximately I 20,000, of whom a vast majority are Hindu. All major Hindu castes are represented in the district. The economy is basically agricultural, although some males work also in metropolitan Calcutta. The main crop is rice, which is harvested twice a year. In addition, a variety of vegetables and fruit-producing trees are cultivated. Jute is the main cash crop and is sold in Calcutta. The main domestic animals are cattle, goats, and ducks. Most households in the district have about three head of cattle, while goats average less than one per family (26). Diet is determined by religious and economic restrictions, both of which discourage the consumption of animals but encourage the consumption of vegetarian products (27). Fish in the many ponds is the most available source of animal protein, since other animal protein foods (milk, meat, eggs) are mostly sold in the local markets or in Calcutta. A 1957 survey (28) indicated that the majority of the population (96%) were nonvegetarians. Only 44% of the people were classified as nutritionally normal, while about 54% suffered from a mild to moderate degree of protein-calorie malnutrition. The reported average weight for women was 39.5 kg, and for men 44.7 kg (28).
NUTRITION Infant
feeding
AND
BEHAVIOR
practices
Breast feeding
is common
and often
prolonged
beyond
the 2nd year oflife (29). The
rice ceremony Anna prashan is celebrated during the 6th or 7th month of the infant’s life. After the ceremony supplementary food, carbohydrate gruels or gruels combined with adult food, is added into the infant’s diet.
The onset of
malnutrition
in small
children
is primar-
ily due to the unavailability of suitable foods and to deficits in food distribution even when suitable foods are available (30). The main reasons for not utilizing the available foods in infants’ diets are the lack of knowledge of the foods that small children can and should eat and the lack of adequate maternal care (30). Maternal
ignorance,
low
motivation
and concern
for the child’s
well-being, and lack of resourcefulness in caregiving are considered the key determinants in the degree of malnutrition of the child (30). Another reason is connected with beliefs, taboos, and traditions linked with food habits. Thus, foods high in protein (meat, fish, eggs) are frequently considered too rich and heavy for small children (30). Also, the belief that most foods should be withheld from children during any illness may contribute to chronic malnutrition in infancy and early childhood.
The abrupt the infant’s
introduction
of
highly
spiced
adult
foods
in
diet after Anna prashan without a preceding introduction of suitable infant foods frequently causes diarrhea and other gastrointestinal symptoms (Dr. Joyce Biswas,
only
personal
barley
communication).
Since
traditionally
during diarrhea, considerable weight loss often results. The loss of weight may reduce the child’s resistance to illness, providing for further bouts of diarrhea. Seal et al. (28) estimated that among Singur District children under 5 years of age, 42% could be considered nutritionally normal, the remaining 58% suffering from varying
The
water
degrees
is given
of
protein-calorie
malnutrition.
subjects
The study’s
sample
children health
attending clinic (H.
Local
height
and
was randomly selected among the the district’s maternity and child J. Mukherjee Health School, Singur). weight
norms
were
available
weight
(31); initially
PILOT
307
STUDY
100, has been developed and standardized in South India (35). This index is independent of age, takes into consideration weight in relation to length, and is significantly correlated with other anthropometric measures, such as weight and arm circumference. The classification followed in this study was to consider children with an index 0. 15 or greater as well-nourished, and children with an index 0. 14 or less as undernourished. Interestingly, the mean index for the well-nourished group was 0.18 (SD = 0.01), which was considerably higher than in the South Indian normal sample. Further, unlike the results in the South Indian study, no sex differences were found. The second anthropometric measure used was midarm/head circumference ratio. This ratio has been shown
to
be unaffected
between reliability folIowin
by
sex differences,
6 months and with weight classification
nutritionally
healthy;
malnutrition;
0.309-0.280,
0.279
to
be constant
4 years of age, and to show high for age percentage (36). The has been suggested: 0.31O, mild
-0.250,
protein-calorie
moderate
malnutrition;
O.25O, severe malnutrition (36). The midarm/head circumference ratio was at or above 0.310 for the well-nourished children, and below 0.280 for the undernourished children. The three anthropometric measures were highly intercorrelated: weight with (weight/length’)
x 100, r = 0.79, P < 0.001, and with midarm/head circumference, r = 0.58, P < 0.001; (weight/length’) x 100 with midarm/head circumference, r = 0.70, P < 0.001. The final sample fulfilling the above three anthropometric criteria consisted of 39 well-nourished children and 23 undernourished children; used to determine the environmental parameters. Table I gives the means viations
in the
this sample
anthropometric
tritional was not
groups, including chest circumference, which used in the selection of the study children. A pediatric examination confirmed that at the time of the study the children were otherwise healthy. The intention was to match the two nutritional groups for age and sex. Within the total age range (from 7 through 18 months), two age groups were separated for further developmental comparisons. The younger age
group,
from
7 through
well-nourished
and
I I
12 months
of
undernourished
age,
had
dren. As to sex, the well-nourished group had and 20 girls. Among the undernourished children
(32)
groups.
to
the
well-nourished
children’s
weights
were
be-
tween the 80th and the 95th percent standards and the undernourished children’s weights were between the 60th and the 65th percent standards, and, according to Gomez’s classification (33), the undernourished children were in the lower range of second degree malnutrition (60 to 75%). Although weight for known age is stated to be the
most sensitive
and useful
indicator
of nutritional
status,
especially during the first 2 years (34), this indicator may be influenced by factors other than the nutritional, such as genetic potential. Therefore, two other anthropometnc measures were used to select further the children for the two nutritional groups. An index, (weight/length2) x
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/3/305/4648806 by guest on 08 February 2018
older
age group,
included
but
only
from
13 through
20 well-nourished
seven
girls
and
were
located
18 months
The
of age,
12 undernourished
for
the mean ages for boys and girls To compare the sample with the of the clinic, a survey was made children on file who were between months during the time of the
19
children.
for known age on these norms was determine in which of the two nutritional groups the child belonged. A well-nourished child’s weight at the time of selection was above the 70th percentile, and an undernourished child’s weight was below the 30th percentile. On the international norms used
was
and nutritional and standard demeasures for the two nu-
study.
chil-
19 boys 16 boys
Table
2 gives
in the two nutritional overall child clientele of all of the district’s the ages of 7 and 18 study and thus were
theoretical candidates for the study. The files contained information on children who attended the clinic and on children whose development was followed only through
nurses’
home
visits.
Three
facts
emerged
elaboration. First, there were 488 children in the the ages of 7 and 18 months at the time
these approximately Since the children
that
need
district between of the study. Of
one-third (166) attended were selected for study
the clinic. from this
GRAVES
308 TABLE Means
I and standard
deviations
for the anthropometric
measures
Anthropometric
measures:
Well-n
8.2
SD (cm)
Head circumference
(cm)
circumference
(Weight/length’) Midarm/head
SD
ratio
b
TABLE 2 Mean ages (in months)
Robert
J.D.,
international
Ph.D.
nutrition
Nutrition, infant behavior, and maternal characteristics: a pilot study in West Bengal, India1’2 Pirkko
Lauslahti
Graves,3
Mag.
ABSTRACT
Free
among
undernourished
Bengal.
The
the
mother,
her
more
lower scores
Phil.,
and
especially frequently
revealed
maternal
scores Nutr.
boys
than
in four
and
mother-child
well-nourished
did
reciprocity
showed
a divergent
29: 305-3
19, 1976.
boys. The not different. pattern
Journal
of Clinical
Nutrition
29: MARCH
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/3/305/4648806 by guest on 08 February 2018
the ages activity,
and The
behavior.
in mother-child
Malnutrition is a complex product of economic, social, biological, and psychological factors (1-3). Its impact on human behavior and development ranges from biochemical and physical to psychological changes, which may even extend over generations (4-6). Among the psychological changes, learning ability is the most frequently documented function affected by malnutrition (3, 7-9). The link between malnutrition and learning ability is complex (1), and the following possibilities are offered to define a causative linkage: central nervous system damage; reduced learning time and/or responsiveness as a result of malnutrition; or interference of malnutrition during critical periods of learning (7). One critical period of learning is that of early infantile experience, which is strongly influenced by the nature of the infant’s relationship with his mother (10, 11). The mother is the source of the infant’s physical and emotional satisfaction, and acts as a mediator and a source of stimulation for the infant. Total or partial failure in either of these The American
boys.
of maternal
undernourished boys were
in play
a distance,
the well-nourished
in a standard
between
less vigor
across
of six measures
a high
interaction
children
showed
in interaction
of reciprocity for the well- and undernourished J. Clin.
activities
undernourished
scores
Ph.D.
setting
of 7 and
were
18 months
less attachment
maintained mothers
close between
physical child
interaction
for the well-nourished
developmental However,
quotient and activity the correlations between
of relationships
for the two
nutritional
in West
behavior
toward
contact
of the undernourished
Correlations
observed
with
boys and
boys,
had
maternal but
a lack
scores of the these and the
groups.
Am.
major functions of mothering may adversely affect the infant’s intellectual and socioemotional development, as shown in studies on maternal deprivation and separation ( I 2, 13). Conversely, mothering which provides environmental stimulation and enrichment may have long-term enhancing effects on the infant’s cognitive and socioemotional development, as shown by studies on psychosocial enrichment (13). The contemporary trend in child developmental research, with its emphasis on studying
the
ongoing
mother-child
has advanced our knowledge maternal care components specific infant development
relationship,
of the specific that influence components in
‘From the Department of Pathobiology, The Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland 21205. 2This project was supported by Grant 5 R07 A1I0048-14, awarded by the National Institutes of Health, Department of Health, Education, and Welfare to the Department of Pathobiology, The Johns Hopkins University School of Hygiene and Public Health. International Center for Medical Research. ‘Assistant Professor.
1976,
pp.
305 -3I9.
Printed
in U .S.A.
305
306
GRAVES
both the intellectual and socioemotional spheres (I 1, 14-17). The findings support the notion that mutual adaptation and reinforcement between the mother and the young child play an important role in the child’s psychological growth ( 1 1 , 18-19). The purpose of the present study was to explore whether differences in specific cornponents of infant behavior and of maternal behavior could be detected between poorly nourished and adequately nourished young children. An assessment of behavioral differences and differences in mother-child interaction would be a necessary first step toward the goal of specifying the influence of early infantile experience on the malnourished child’s development, including learning. Based on theoretical considerations and on the existing research evidence, four major behavioral categories were selected for the assessment. The first and second categories were the child’s attachment behavior toward the mother and maternal behavior toward the child. As stated, the role of the mother is not only important for the infant’s physical and socioemotional development, but it also influences the infant’s intellectual development (11, 14, 20). The child’s attachment behavior,
that
is,
behavior
that
promotes
contact and/or proximity to the mother (16), gives information about the nature of the mother-child tie. A secure tie enables the child to maintain a dynamic balance between his attachment and exploratory behaviors (16). An insecure tie, in contrast, disturbs this balance and contributes to deficits in exploratory behavior as well as to a poorer intellectual performance (21). The child’s irritability, in the form of whimpering and crying, was selected as a third behavioral category. Although basically attachment behaviors (16), whimpering and crying reportedly are characteristic behaviors among malnourished children (22, 23). The child’s exploratory behavior was selected as the fourth category because it plays a central role in intellectual development. A large body of recent experimental work provides evidence that intellectual ability is influenced by experience, in particular by early infantile experience (10, 11, 15). Through exploratory behavior the infant expands his experience and acquires
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/3/305/4648806 by guest on 08 February 2018
and exercises new skills. Concerning malnourished children, it has been suggested that the attendant low level of activity may not only interfere with the child’s capacity to explore, but would also elicit less response from the mother, which in turn would contribute to retarded behavioral development (3, 24). Moderate malnutrition, that is, chronic undernutrition, characterized by restricted food intake both in quantity and in quality (3), was selected for study, rather than severe forms of malnutrition caused by inadequate food intake (kwashiorkor, marasmus) (3). Severe cases were available, but were avoided in the present study because the worldwide problem is chronic undernutrition (25). If behavioral alterations could be detected among the undernourished children when compared with adequately nourished children, the findings would have wider implications than would findings from severely malnourished children. Subjects The study
and
methods
area
The study was done in Singur District, West Bengal, India, between November 1971 and June 1972. The district, composed of a dozen or so adjacent small villages within an area of 57 square miles, is located approximately 25 miles northwest of Calcutta and has good highway and railway connections with Calcutta. The population is approximately I 20,000, of whom a vast majority are Hindu. All major Hindu castes are represented in the district. The economy is basically agricultural, although some males work also in metropolitan Calcutta. The main crop is rice, which is harvested twice a year. In addition, a variety of vegetables and fruit-producing trees are cultivated. Jute is the main cash crop and is sold in Calcutta. The main domestic animals are cattle, goats, and ducks. Most households in the district have about three head of cattle, while goats average less than one per family (26). Diet is determined by religious and economic restrictions, both of which discourage the consumption of animals but encourage the consumption of vegetarian products (27). Fish in the many ponds is the most available source of animal protein, since other animal protein foods (milk, meat, eggs) are mostly sold in the local markets or in Calcutta. A 1957 survey (28) indicated that the majority of the population (96%) were nonvegetarians. Only 44% of the people were classified as nutritionally normal, while about 54% suffered from a mild to moderate degree of protein-calorie malnutrition. The reported average weight for women was 39.5 kg, and for men 44.7 kg (28).
NUTRITION Infant
feeding
AND
BEHAVIOR
practices
Breast feeding
is common
and often
prolonged
beyond
the 2nd year oflife (29). The
rice ceremony Anna prashan is celebrated during the 6th or 7th month of the infant’s life. After the ceremony supplementary food, carbohydrate gruels or gruels combined with adult food, is added into the infant’s diet.
The onset of
malnutrition
in small
children
is primar-
ily due to the unavailability of suitable foods and to deficits in food distribution even when suitable foods are available (30). The main reasons for not utilizing the available foods in infants’ diets are the lack of knowledge of the foods that small children can and should eat and the lack of adequate maternal care (30). Maternal
ignorance,
low
motivation
and concern
for the child’s
well-being, and lack of resourcefulness in caregiving are considered the key determinants in the degree of malnutrition of the child (30). Another reason is connected with beliefs, taboos, and traditions linked with food habits. Thus, foods high in protein (meat, fish, eggs) are frequently considered too rich and heavy for small children (30). Also, the belief that most foods should be withheld from children during any illness may contribute to chronic malnutrition in infancy and early childhood.
The abrupt the infant’s
introduction
of
highly
spiced
adult
foods
in
diet after Anna prashan without a preceding introduction of suitable infant foods frequently causes diarrhea and other gastrointestinal symptoms (Dr. Joyce Biswas,
only
personal
barley
communication).
Since
traditionally
during diarrhea, considerable weight loss often results. The loss of weight may reduce the child’s resistance to illness, providing for further bouts of diarrhea. Seal et al. (28) estimated that among Singur District children under 5 years of age, 42% could be considered nutritionally normal, the remaining 58% suffering from varying
The
water
degrees
is given
of
protein-calorie
malnutrition.
subjects
The study’s
sample
children health
attending clinic (H.
Local
height
and
was randomly selected among the the district’s maternity and child J. Mukherjee Health School, Singur). weight
norms
were
available
weight
(31); initially
PILOT
307
STUDY
100, has been developed and standardized in South India (35). This index is independent of age, takes into consideration weight in relation to length, and is significantly correlated with other anthropometric measures, such as weight and arm circumference. The classification followed in this study was to consider children with an index 0. 15 or greater as well-nourished, and children with an index 0. 14 or less as undernourished. Interestingly, the mean index for the well-nourished group was 0.18 (SD = 0.01), which was considerably higher than in the South Indian normal sample. Further, unlike the results in the South Indian study, no sex differences were found. The second anthropometric measure used was midarm/head circumference ratio. This ratio has been shown
to
be unaffected
between reliability folIowin
by
sex differences,
6 months and with weight classification
nutritionally
healthy;
malnutrition;
0.309-0.280,
0.279
to
be constant
4 years of age, and to show high for age percentage (36). The has been suggested: 0.31O, mild
-0.250,
protein-calorie
moderate
malnutrition;
O.25O, severe malnutrition (36). The midarm/head circumference ratio was at or above 0.310 for the well-nourished children, and below 0.280 for the undernourished children. The three anthropometric measures were highly intercorrelated: weight with (weight/length’)
x 100, r = 0.79, P < 0.001, and with midarm/head circumference, r = 0.58, P < 0.001; (weight/length’) x 100 with midarm/head circumference, r = 0.70, P < 0.001. The final sample fulfilling the above three anthropometric criteria consisted of 39 well-nourished children and 23 undernourished children; used to determine the environmental parameters. Table I gives the means viations
in the
this sample
anthropometric
tritional was not
groups, including chest circumference, which used in the selection of the study children. A pediatric examination confirmed that at the time of the study the children were otherwise healthy. The intention was to match the two nutritional groups for age and sex. Within the total age range (from 7 through 18 months), two age groups were separated for further developmental comparisons. The younger age
group,
from
7 through
well-nourished
and
I I
12 months
of
undernourished
age,
had
dren. As to sex, the well-nourished group had and 20 girls. Among the undernourished children
(32)
groups.
to
the
well-nourished
children’s
weights
were
be-
tween the 80th and the 95th percent standards and the undernourished children’s weights were between the 60th and the 65th percent standards, and, according to Gomez’s classification (33), the undernourished children were in the lower range of second degree malnutrition (60 to 75%). Although weight for known age is stated to be the
most sensitive
and useful
indicator
of nutritional
status,
especially during the first 2 years (34), this indicator may be influenced by factors other than the nutritional, such as genetic potential. Therefore, two other anthropometnc measures were used to select further the children for the two nutritional groups. An index, (weight/length2) x
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/3/305/4648806 by guest on 08 February 2018
older
age group,
included
but
only
from
13 through
20 well-nourished
seven
girls
and
were
located
18 months
The
of age,
12 undernourished
for
the mean ages for boys and girls To compare the sample with the of the clinic, a survey was made children on file who were between months during the time of the
19
children.
for known age on these norms was determine in which of the two nutritional groups the child belonged. A well-nourished child’s weight at the time of selection was above the 70th percentile, and an undernourished child’s weight was below the 30th percentile. On the international norms used
was
and nutritional and standard demeasures for the two nu-
study.
chil-
19 boys 16 boys
Table
2 gives
in the two nutritional overall child clientele of all of the district’s the ages of 7 and 18 study and thus were
theoretical candidates for the study. The files contained information on children who attended the clinic and on children whose development was followed only through
nurses’
home
visits.
Three
facts
emerged
elaboration. First, there were 488 children in the the ages of 7 and 18 months at the time
these approximately Since the children
that
need
district between of the study. Of
one-third (166) attended were selected for study
the clinic. from this
GRAVES
308 TABLE Means
I and standard
deviations
for the anthropometric
measures
Anthropometric
measures:
Well-n
8.2
SD (cm)
Head circumference
(cm)
circumference
(Weight/length’) Midarm/head
SD
ratio
b
TABLE 2 Mean ages (in months)
